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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services: STATE OF IL (STATESMHNO)Health Network Only - State HNOCoverage Period: 07/01/2020 - 06/30/2021Coverage for: Individual Family Plan Type: HMOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of docs?u 082900-040020-362022 or by calling 1-800-370-4526. For general definitions of common terms, such asallowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary athttps://www.healthcare.gov/sbc-glossary/ or call 1-800-370-4526 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overalldeductible?See the Common Medical Events chart below for your costs for services this plancovers.For each Plan Year, 0.Are there servicescovered before you meet No.your deductible?Are there otherYes. 125 for prescription drugs. There are no otherdeductibles for specificspecific deductibles.services?What is the out-of-pocket In-Network: Individual 3,000 / Family 6,000.limit for this plan?What is not included inthe out-of-pocket limit?Will you pay less if youuse a network provider?You will have to meet the deductible before the plan pays for any services.You must pay all of the costs for these services up to the specific deductible amountbefore this plan begins to pay for these services.The out-of-pocket limit is the most you could pay in a year for covered services. If youhave other family members in this plan, they have to meet their own out-of-pocketlimits until the overall family out-of-pocket limit has been met.Premiums, balance-billing charges & health care thisplan doesn't cover.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.Yes. See http://www.aetna.com/docfind or call1-800-370-4526 for a list of in-network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’snetwork. You will pay the most if you use an out-of-network provider, and you mightreceive a bill from a provider for the difference between the provider's charge and whatyour plan pays (balance billing). Be aware, your network provider might use anout-of-network provider for some services (such as lab work). Check with your providerbefore you get services.Do you need a referral to No.see a specialist?You can see the specialist you choose without a referral.Published: 05/05/2020082900-040020-362022 1 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventIf you visit a health careprovider’s office or clinicWhat You Will PayServices You May NeedLimitations, Exceptions, & Other ImportantOut–of–NetworkIn-Network Provider (You ProviderInformation(You will paywill pay the least)the most)Primary care visit to treat an injury or 25 copay/visitillnessSpecialist visit 35 copay/visitPreventive care /screening/immunizationNo chargeNo charge 25 copay/visitCopay/prescription, afterspecific deductible: Tier 1A 4 for 30 day supply(retail), 10 for 31-90 dayPreferred generic drugs (Includessupply (retail & mail order);Tier 1A - Value Drugs and Tier 1Preferred Generic Prescription Drugs) Preferred Generic 13 for30 day supply (retail),If you need drugs to treat 32.50 for 31-90 dayyour illness or conditionsupply (retail & mail order)Copay/prescription, afterMore information aboutprescription drugspecific deductible: 31 forcoverage is available at30 day supply (retail),Preferred brand drugswww.aetnapharmacy.com/p 77.50 for 31-90 dayremiersupply (retail & mail order)Copay/prescription, afterspecific deductible: 55 for30 day supply (retail),Non-preferred generic/brand drugs 137.50 for 31-90 daysupply (retail & mail order)Applicable cost as notedSpecialty drugsabove for generic or branddrugsIf you have a testDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs)Published: 05/05/2020Not coveredNoneNot coveredNoneYou may have to pay for services that aren'tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for.NoneNoneNot coveredNot coveredNot coveredNot coveredNot coveredCovers 30 day supply (retail), 31-90 day supply(retail & mail order). Includes contraceptivedrugs & devices obtainable from a pharmacy,oral & injectable fertility drugs. No charge forpreferred Generic FDA-approved women'scontraceptives in-network. Review yourformulary for prescriptions requiringprecertification or step therapy for coverage.Your cost will be higher for choosing Brandover Generics.Not coveredNot coveredAll prescriptions must be filled through theAetna Specialty Pharmacy Network.082900-040020-362022 2 of 6

CommonMedical EventWhat You Will PayServices You May NeedLimitations, Exceptions, & Other ImportantOut–of–NetworkIn-Network Provider (You ProviderInformation(Youwillpaywill pay the least)the most)Facility fee (e.g., ambulatory surgerycenter)Physician/surgeon feesEmergency room care 275 copay/visitNot coveredNoneNo charge 275 copay/visitNot covered 275 copay/visitIf you need immediatemedical attentionEmergency medical transportationNo chargeNo chargeIf you have ahospital stayUrgent careFacility fee (e.g., hospital room)Physician/surgeon fees 35 copay/visit 375 copay/stayNo chargeNot coveredNot coveredNot coveredNoneNo coverage for non-emergency use.Non-emergency transport: not covered, exceptif pre-authorized.No coverage for non-urgent use.NoneNoneOutpatient servicesOffice: 35 copay/visit;other outpatient services:no chargeNot coveredNoneInpatient services 375 copay/stayNot coveredNoneOffice visitsChildbirth/delivery professionalservicesChildbirth/delivery facility servicesHome health careNo chargeNot coveredNo chargeNot covered 375 copay/stay 35 copay/visitNot coveredNot coveredCost sharing does not apply for preventiveservices. Maternity care may include testsand services described elsewhere in the SBC(i.e. ultrasound.)Rehabilitation services 35 copay/visitNot coveredHabilitation services 35 copay/visitNot coveredSkilled nursing careNo chargeNot coveredDurable medical equipment20% coinsuranceNot coveredHospice servicesChildren's eye examChildren's glassesChildren's dental check-upNo chargeNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredIf you have outpatientsurgeryIf you need mental health,behavioral health, orsubstance abuse servicesIf you are pregnantIf you need helprecovering or have otherspecial health needsIf your child needs dentalor eye carePublished: 05/05/2020None60 visits/calendar year for Physical,Occupational & Speech Therapy combined.NoneNoneLimited to 1 durable medical equipment forsame/similar purpose. Excludes repairs formisuse/abuse.NoneNot covered.Not covered.Not covered.082900-040020-362022 3 of 6

Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Cosmetic surgery Dental care (Adult & Child) Glasses (Child) Long-term care Non-emergency care when traveling outside theU.S. Private-duty nursing Routine eye care (Adult & Child) Routine foot care Weight loss programs - Except for requiredpreventive services.Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric surgery Chiropractic care Hearing aids - 1 hearing aid per ear/36 months up toage 18 & 1 hearing aid to 2,500 maximum perear/24 months thereafter. Infertility treatment - Limited to the diagnosis &treatment of underlying medical condition, artificialinsemination, ovulation induction & advancedreproductive technology. Oocyte retrievals:4/lifetime, if live birth 2 additional/lifetime.Your Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Illinois Department of Insurance, Office ofConsumer Health Insurance, 1-877-527-9431 toll free, 1-866-323-5321 (TDD), http://insurance.illinois.gov/. For more information on your rights to continue coverage, contact the plan at 1-800-370-4526. If your group health coverage is subject to ERISA, you may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA(3272) or https://www.dol.gov/agencies/ebsa.For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information andInsurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals shouldcontact their State insurance regulator regarding their possible rights to continuation coverage under State law.Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information aboutthe Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information aboutyour rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or agrievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Aetna directly by calling the toll free number on your Medical ID Card, or by calling our general toll free number at 1-800-370-4526. Illinois Department of Insurance, Office of Consumer Health Insurance, 1-877-527-9431 toll free, 1-866-323-5321 (TDD), http://insurance.illinois.gov/. If your group health coverage is subject to ERISA, you may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA(3272) or https://www.dol.gov/agencies/ebsa.Published: 05/05/2020082900-040020-362022 4 of 6

For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information andInsurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.Additionally, a consumer assistance program can help you file your appeal. Contact Office of Consumer Health Insurance, Consumer Services Section, 122 SouthMichigan Avenue, 19th floor, Chicago, IL 60603, Or 320 W. Washington Street, Springfield, IL 62767-0001, 877-527-9431, 1-866-323-5321 (TDD),http://insurance.illinois.gov/Does this plan provide Minimum Essential Coverage? Yes.If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from therequirement that you have health coverage for that month.Does this plan meet Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.-------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.-------------------Published: 05/05/2020082900-040020-362022 5 of 6