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Choosing Your PlanSometimes choosing a health plan that works best for you and your family can be confusing. There are several pages in this guide designed to helpyou better understand each plan. This page begins with some basic questions and highlights of each plan. You’ll find more detailed information oneach health plan on pages 10-21.LivingWell CDHPLivingWell PPOLivingWell Basic CDHPDo you want to pay lowerpremiums and receive money inan HRA to help reduce yourdeductible? LivingWell CDHP maybe the plan for you! It’s the richestplan offered by KEHP, and it isrecommended for those who have alittle or a lot of healthcare expenses.Both your medical and pharmacyexpenses apply to the out-of-pocketmaximum, and once met, yourcovered medical and pharmacyclaims will be paid at 100%.Are you willing to pay more inpremiums to have just a co-paymentfor doctor’s office visits, allergyshots, urgent care centers, andprescriptions? Are you comforted inknowing upfront what you will have topay for those services? LivingWellPPO may be the plan for you. However,even though you have co-pays for someservices, most expenses are subject tothe deductible and then covered at80%. Plus, this plan has two out-ofpocket maximums — one is for medicalexpenses and the other is forprescription expenses, which meansyou will pay more out of your pocket.Some services you will always have topay for since co-pays do not apply to thedeductible. The choice is up to you!How about basic health insurancecoverage and cheaper premiums,and an HRA to help reduce yourdeductible? LivingWell Basic CDHPis just that — basic coverage for avery low premium, but still a greatplan. You will pay 30% for coveredservices after you meet yourdeductible. Both your medical andpharmacy expenses apply to theout-of-pocket maximum, and oncemet, your covered medical andpharmacy claims will be paid at 100%.8LivingWell LimitedHigh DeductibleThis is a catastrophic-type planwith the cheapest premium.Be careful in selecting theLivingWell High Deductible Plan;it is NOT the plan for most people.This plan should only be consideredif you want the lowest premiums andexpect you won’t need healthcoverage. This plan comes witha very high deductible andout-of-pocket maximum. You will pay50% for covered services after youmeet your deductible. Both yourmedical and pharmacy expensesapply to the out-of-pocketmaximum. After you meet yourout-of-pocket maximum, yourmedical and pharmacy claimswill be paid at 100%.

Choosing Your PlanThe in-network benefit highlights for the four plan options are below; see pages 10-21 for details. Premiums listed below are per month forsingle coverage, a non-tobacco user who fulfilled the LivingWell Promise.In-Network Medical BenefitsLivingWell CDHPLivingWell PPOLivingWell Basic CDHPLivingWell LimitedHigh DeductiblePremiums 52.42Premiums 87.40Premiums 27.78Premiums 25.00HRASingle 500Family 1,000No HRASingle 250Family 500No HRADeductibleSingle 1,500Family 2,750Single 1,000Family 1,750Single 2,000Family 3,750Single 4,250Family 8,250Out-of-pocket MaximumSingle 3,000Family 5,750Single 3,000Family 5,750Single 4,000Family 7,750Single 5,250Family 10,250Doctor’s VisitDeductible then 15%Co-pay 25;Specialist 50Deductible then 30%Deductible then 50%Co-insurance15%20%30%50%In-Network Prescription BenefitsPrescriptions30-day supplyValue FormularyPrescriptionsout-of-pocket maximumTier 1: Deductible then 15%Tier 2: Deductible then 15%Tier 1: 15Tier 2: 40Tier 1: Deductible then 30%Tier 2: Deductible then 30%Tier 1: Deductible then 50%Tier 2: Deductible then 50%Combined with MedicalSingle 2,500Family 5,000Combined with MedicalCombined with MedicalAll plans use the 2-tier Value Formulary for 2021.9

LivingWell CDHPThe LivingWell Consumer Driven Health Plan (CDHP)Pay lower premiums and receive money in an HRA.Use the HRA to help meet your deductible}You will receive a debit VISA Healthcare Card that is pre-funded with 500 if you havesingle coverage or 1,000 if you have couple, parent-plus, or family coverage levels.HealthEquity and WageWorks merged to create a new benefits partner for KEHP.If you have the orange WageWorks debit VISA Healthcare Card, you will not receivea new HealthEquity card until your WageWorks card expires.}Use the HRA to help pay for your co-insurance, which reduces your deductible.}Use this card at your doctor’s office, hospital, or pharmacy. Simply swipe the card tohelp pay for your eligible expenses, which will be deducted from your card balance.}You can also use this card to pay for eligible vision and dental expenses; theseexpenses do not reduce your deductible.How the LivingWell CDHP worksBefore any expenses are paid by the LivingWell CDHP (except preventiveservices, which are paid at 100%):You must meet your deductible amount (except for specificprescriptions, see page 27). You can use your HRA to helppay for or reduce your deductible amount — see next page.The LivingWell CDHP will then start paying 85% of covered medicaland prescription expenses, and you will pay a 15% co-insurance.Both your medical and prescription costs applyto the out-of-pocket maximum — see next page.4000 1234 5678 9010JOHN R. SMITH1012/30

LivingWell CDHP Benefits GridLivingWell CDHP — Plan OptionLifetime ealth Reimbursement Arrangement (HRA)Single 500Family 1,000Annual DeductibleIn-NetworkSingle 1,500Family 2,750Out-of-NetworkSingle 2,750Family 5,250Annual Out-of-Pocket Maximum*(Medical and Prescription out-of-pocket is combined.)In-NetworkSingle 3,000Family 5,750Out-of-NetworkSingle 5,750Family 11,250Co-insuranceIn-NetworkPlan: 85%Member: 15%Out-of-NetworkPlan: 60%Member: 40%Doctor’s Office VisitsIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Annual Prescription Drug Out-of-Pocket Maximum**In-NetworkCombined with MedicalOut-of-NetworkCombined with Medical30-Day Supply of Prescriptions**Tier 1 — GenericTier 2 — FormularyIn-NetworkIn-NetworkDeductible then 15%Deductible then 15%Out-of-NetworkOut-of-NetworkDeductible then 40%Deductible then 40%90-Day Supply of Prescriptions (Retail or Mail Order)**Tier 1 — GenericTier 2 — FormularyIn-NetworkIn-NetworkDeductible then 15%Deductible then 15%Out-of-NetworkOut-of-NetworkNot CoveredNot CoveredPhysician Care (Inpatient/Outpatient/Other)In-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Diagnostic Tests*** in Doctor’s OfficeIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Other LaboratoryIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Inpatient Hospital (Semi-Private Room)In-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Outpatient Hospital/SurgeryIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Outpatient/Ambulatory Surgery CenterIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%11

LivingWell CDHP Benefits GridLivingWell CDHP — Plan OptionEmergency Room(Benefit for emergency medical treatment only.)In-NetworkDeductible then 15%Out-of-NetworkDeductible then 15%ER Physician CareIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 15%AmbulanceIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 15%Urgent Care CenterIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 15%Routine Well ChildIn-NetworkCovered at 100%Out-of-NetworkDeductible then 40%Routine Well AdultIn-NetworkCovered at 100%Out-of-NetworkDeductible then 40%Autism Services and Mental Health(Treated the same as any other health condition. See specifics related to PCP office visit, inpatient, and outpatient services.)Allergy InjectionsIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Allergy SerumIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Maternity Care (See Medical Benefit Booklet for specifics.)In-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Durable Medical EquipmentIn-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Therapy Services(Physical, Occupational, Speech — combined limit of 90 visits per calendar year.)In-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Chiropractic Care(Manipulation Therapy.) Maximum of 26 visits per calendar year; no more than 1 visit per day.In-NetworkDeductible then 15%Out-of-NetworkDeductible then 40%Notes: You can refer to the Summary of Benefits and Coverage (SBC) for more information. KEHP has made every attempt to ensure the accuracy of the benefits outlined in this Benefits Grid. If an errorhas occurred, the benefits outlined in the 2021 Summary Plan Descriptions (SPDs) and Medical Benefit Booklets will determine how benefits are paid. Benefits are subject to the terms, conditions,limitations, and exclusions set forth in the SPDs.* All covered expenses apply to the out-of-pocket maximum, except routine well child and routine well adult. Deductibles & Out-of-Pocket Maximums for In-Network and Out-of-Network providersaccumulate separately and do not cross apply.** Certain drugs to treat diabetes, COPD, and asthma are subject to reduced co-insurance with no deductibles. Select preventive/maintenance drugs bypass the deductible.*** Claims are processed based on provider billing type, which may include separate charges from a lab performing services outside of the doctor’s office visit.12

LivingWell PPOThe LivingWell Preferred Provider Organization (PPO)Pay higher premiums and have co-pays for some services.How the LivingWell PPO worksYou Pay:A co-paymentDoctor visitsDiagnostic tests in the doctor’s officePrescriptionsAllergy injectionsAllergy serumUrgent care centersA co-payment plusyour deductibleEmergency roommedical treatmentA deductible and then20% co-insuranceAll other covered servicesYour co-pays will not apply to your deductible.Your co-pays will apply to your out-of-pocket maximum.You have a medical out-of-pocket maximum plus a prescriptionout-of-pocket maximum, and they accumulate separately.Free 24/7 NurseLine at 877-636-3720.13

LivingWell PPO Benefits GridLivingWell PPO — Plan OptionLifetime ealth Reimbursement Arrangement (HRA)NoneAnnual Deductible*In-NetworkSingle 1,000Family 1,750Out-of-NetworkSingle 1,750Family 3,250Annual Medical Out-of-Pocket Maximum**(Applies to medical only — separate from the prescription out-of-pocket maximum.)In-NetworkSingle 3,000Family 5,750Out-of-NetworkSingle 5,750Family 11,250Member: 20%Out-of-NetworkPlan: 60%Member: 40%Out-of-NetworkDeductible then 40%Out-of-NetworkSingle 5,000Co-insuranceIn-NetworkPlan: 80%Doctor’s Office VisitsIn-NetworkCo-pay:* 25 PCP; 50 SpecialistAnnual Prescription Drug Out-of-Pocket Maximum**(Applies to prescriptions and separate from medical.)In-NetworkSingle 2,50030-Day Supply of Prescriptions***Tier 1 — GenericTier 2 — FormularyIn-NetworkIn-Network 15 40Out-of-NetworkOut-of-Network 30 8090-Day Supply of Prescriptions (Retail or Mail Order)***Tier 1 — GenericTier 2 — FormularyIn-NetworkIn-Network 30 80Out-of-NetworkOut-of-NetworkNot CoveredNot CoveredPhysician Care (Inpatient/Outpatient/Other)In-NetworkDeductible then 20%Out-of-NetworkDeductible then 40%Diagnostic Tests**** in Doctor’s OfficeIn-NetworkOffice Visit Co-pay*Out-of-NetworkDeductible then 40%Other LaboratoryIn-NetworkDeductible then 20%Out-of-NetworkDeductible then 40%Inpatient Hospital (Semi-Private Room)In-NetworkDeductible then 20%Out-of-NetworkDeductible then 40%Outpatient Hospital/SurgeryIn-NetworkDeductible then 20%Out-of-NetworkDeductible then 40%Outpatient/Ambulatory Surgery CenterIn-NetworkDeductible then 20%Out-of-NetworkDeductible then 40%14Family 5,000Family 10,000

LivingWell PPO Benefits GridLivingWell PPO — Plan OptionEmergency Room(Benefit for emergency medical treatment only.)In-Network 150 Co-pay* then Deductible then 20%. Co-pay* waived if admittedOut-of-Network 150 Co-pay* then Deductible then 20%. Co-pay* waived if admittedER Physician CareIn-NetworkDeductible then 20%Out-of-NetworkDeductible then 20%AmbulanceIn-NetworkDeductible then 20%Out-of-NetworkDeductible then 20%Urgent Care CenterIn-Network 50 Co-pay*Out-of-Network 50 Co-pay*Routine Well ChildIn-NetworkCovered at 100%Out-of-NetworkDeductible then 40%Routine Well AdultIn-NetworkCovered at 100%Out-of-NetworkDeductible then 40%Autism Services and Mental Health(Treated the same as any other health condition. See specifics related to PCP office visit, inpatient, and outpatient services.)Allergy InjectionsIn-Network 15 Co-pay*Out-of-NetworkDeductible then 40%Allergy SerumIn-Network 15 Co-pay*Out-of-NetworkDeductible then 40%Maternity Care (See Medical Benefit Booklet for specifics.) In-Network 25 Co-pay* (office visit pregnancy diagnosed) Delivery Charge: Deductible then 20%Out-of-NetworkDeductible then 40%Deductible then 20%Out-of-NetworkDeductible then 40%Therapy Services(Physical, Occupational, Speech — combined limit of 90 visits per calendar year.)In-NetworkDeductible then 20%Out-of-NetworkDeductible then 40%Chiropractic Care(Manipulation Therapy.) Maximum of 26 visits per calendar year; no more than 1 visit per day.In-Network 25 Co-pay*Out-of-NetworkDeductible then 40%Durable Medical EquipmentIn-NetworkNotes: You can refer to the Summary of Benefits and Coverage (SBC) for more information. KEHP has made every attempt to ensure the accuracy of the benefits outlined in this Benefits Grid. If an errorhas occurred, the benefits outlined in the 2021 Summary Plan Descriptions (SPDs) and Medical Benefit Booklets will determine how benefits are paid. Benefits are subject to the terms, conditions,limitations, and exclusions set forth in the SPDs.* Co-pays do not accumulate toward the deductible, but they do accumulate toward the applicable out-of-pocket maximum.** All covered expenses apply to the out-of-pocket maximum, except routine well child and routine well adult. The out-of-pocket maximum accumulates separately and independently for medical andprescription drug benefits.*** Certain drugs to treat diabetes, COPD, and asthma are subject to reduced co-pays with no deductibles.**** Claims are processed based on provider billing type, which may include separate charges from a lab performing services outside of the doctor’s office visit.15

LivingWell Basic CDHPThe LivingWell Basic CDHPA basic health plan with low premiums, and an HRA to help reduceyour deductible.Use the HRA to help meet your deductibleHow about basic health insurance coverage and cheaper premiums, and an HRA tohelp reduce your deductible? The LivingWell Basic CDHP is just that – basic coveragefor a very low premium, but still a great plan. You will pay 30% for covered servicesafter you meet your deductible. Both your medical and pharmacy expenses applyto the out-of-pocket maximum, and once met, your covered medical and pharmacyclaims will be paid at 100%.How the LivingWell CDHP Basic worksBefore any expenses are paid by the LivingWell Basic CDHP (except preventiveservices, which are paid at 100%):You must meet your deductible amount (except for specific prescriptions,see page 27). You can use your HRA to help pay for or reduce your deductibleamount — see next page.The LivingWell Basic CDHP will then start paying 70% of covered medicaland prescription expenses, and you will pay a 30% co-insurance.Both your medical and prescription costs apply to the out-of-pocketmaximum — see next page.4000 1234 5678 9010JOHN R. SMITH12/30TIP: See page 30 to learn more about aFlexible Spending Account. You can addadditional money to a Healthcare FSAto use with the pre-funded debit VISAHealthcare Card that comes with theLivingWell Basic CDHP.16}You will receive a debit VISA Healthcare Card that is pre-funded with 250 if youhave single coverage or 500 if you have couple, parent-plus, or family coveragelevels. If you have the orange WageWorks debit VISA Healthcare Card, you willnot receive a new HealthEquity card until your WageWorks card expires.}Use the HRA to help pay for your co-insurance, which reduces your deductible.}Use this card at your doctor’s office, hospital, or pharmacy. Simply swipe thecard to help pay for your eligible expenses, which will be deducted from yourcard balance.}You can also use this card to pay for eligible vision and dental expenses; theseexpenses do not reduce your deductible.

LivingWell Basic CDHP Benefits GridLivingWell Basic CDHP — Plan OptionLifetime ealth Reimbursement Arrangement (HRA)Single 250Family 500Annual DeductibleIn-NetworkSingle 2,000Family 3,750Out-of-NetworkSingle 3,250Family 6,250Annual Medical Out-of-Pocket Maximum*(Medical and Prescription out-of-pocket is combined.)In-NetworkSingle 4,000Family 7,750Out-of-NetworkSingle 7,750Family 11,250Co-insuranceIn-NetworkPlan: 70%Member: 30%Out-of-NetworkPlan: 50%Member: 50%Doctor’s Office VisitsIn-NetworkDeductible then 30%Out-of-NetworkDeductible then 50%Annual Prescription Drug Out-of-Pocket Maximum**In-NetworkCombined with MedicalOut-of-NetworkCombined with Medical30-Day Supply of Prescriptions**Tier 1 — GenericTier 2 — FormularyIn-NetworkIn-NetworkDeductible then 30%Deductible then 30%Out-of-NetworkOut-of-NetworkDeductible then 50%Deductible then 50%90-Day Supply of Prescriptions (Retail or Mail Order)**Tier 1 — GenericTier 2 — FormularyIn-NetworkIn-Network

StayWell/WebMD you can earn gift cards for activities like getting a preventive dental visit, completing education sessions, participating in health coaching, or completing step goals.} If you are a cross-reference member, both spouses must fulfill the Promise.} If you waive health insurance, you are eligible for StayWell/WebMD too!