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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesMIDWESTERN UNIVERSITY GLENDALE 500 PLAN:Open Choice Coverage Period: 08/25/2021-08/24/2022Coverage for: Individual Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is onlya summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://www.aetnastudenthealth.com/ or by calling 1 800-927-0783. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-927-0783 to request a copy.Important QuestionsWhat is the overalldeductible?AnswersFor each Plan Year, In-Network: Individual 500. Out-of-Network: Individual 1,000.Are there services coveredbefore you meet yourdeductible?Yes, In-network preventive care are coveredbefore you meet your deductible.Are there other deductiblesfor specific services?What is the out-of-pocketlimit for this plan?What is not included in theout-of-pocket limit?Will you pay less if you use anetwork provider?Do you need a referral to seea specialist?Yes. 50 for prescription drugs. There are noother specific deductibles.In-Network: Individual 3,500.Out-of-Network: Individual 10,000.Premiums, balance-billing charges, health carethis plan doesn't cover & penalties for failure toobtain pre-authorization for services.Yes. See www.aetna.com/docfind or call 1-800 927-0783 for a list of in-network providers.No.Why This Matters:Generally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay.This plan covers some items and services even if you haven't yet met the deductibleamount. But a copayment or coinsurance may apply. For example, this plan coverscertain preventive services without cost sharing and before you meet your deductible.See a list of covered preventive services are-benefits/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.Even though you pay these expenses, they don’t count toward the out–of–pocket limit.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 an out-of network provider for some services (such as lab work). Check with your providerbefore you get services.You can see the specialist you choose without a referral.The Midwestern University Glendale Student Health Insurance Plan is underwritten by Aetna Life Insurance Company (Aetna). Aetna Student Health (SM) is thebrand name used for products and services provided by Aetna Life Insurance Company and its applicable affiliated companies.(c)2021 Aetna Inc.15.02.931.1-AZ A002021-002021-003479Page 1 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Common MedicalEventServices You May NeedPrimary care visit to treat an injury or illnessSpecialist visitIf you visit a healthcare provider’soffice or clinicPreventive care /screening /immunizationIf you have a testDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs)Generic drugsIf you need drugsto treat yourillness orconditionMore informationabout prescriptiondrug coverage isavailable cy.htmlPreferred brand drugsNon-preferred brand drugsSpecialty drugs(c)2021 Aetna Inc.15.02.931.1-AZ AWhat You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most) 25 copay/visit 40 copay/visit 25 copay/visit 40 copay/visitNo charge0% coinsurance15% coinsurance15% coinsuranceCopay/prescription,after specificdeductible: 10(retail), 25 (mailorder)Copay/prescription,after specificdeductible: 45(retail), 112.50(mail order)Copay/prescription,after specificdeductible: 70(retail), 175 (mailorder)35% coinsurance35% coinsurance30% coinsuranceafter copay/prescription, afterspecific deductible: 10 (retail)30% coinsuranceafter copay/prescription, afterspecific deductible: 45 (retail)30% coinsuranceafter copay/prescription, afterspecific deductible: 70 (retail)Copay/prescription,after specificdeductible: 100(retail)30% coinsuranceafter copay/prescription, afterspecific deductible: 100 (retail)Limitations, Exceptions, & Other ImportantInformationNoneNoneYou may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for.NoneNoneCovers 30 day supply (retail), 31-90 day supply(mail order). Includes contraceptive drugs &devices obtainable from a pharmacy. No chargefor preferred generic FDA-approved women'scontraceptives in-network.None002021-002021-003479Page 2 of 6

Common MedicalEventServices You May NeedFacility fee (e.g., ambulatory surgery center)Physician/surgeon feesEmergency room careIf you needimmediate medical Emergency medical transportationattentionUrgent careIf you haveoutpatient surgeryIf you have ahospital stayIf you need mentalhealth, behavioralhealth, orsubstance abuseservicesFacility fee (e.g., hospital room)What You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most)15% coinsurance35% coinsurance15% coinsurance35% coinsurance 200 copay/visit 200 copay/visit 150 copay/trip 150 copay/trip 50 copay/visit 75 copay/visit35% coinsurance,15% coinsurance,after 150after 75 copay/staycopay/stayPhysician/surgeon fees15% coinsuranceOutpatient servicesOffice: 25copay/visit; otheroutpatient services:15% coinsuranceInpatient services35% coinsuranceOffice: 40copay/visit; otheroutpatient services:35% coinsurance35% coinsurance,15% coinsurance,after 150after 75 copay/staycopay/stayOffice visitsNo charge0% coinsuranceChildbirth/delivery professional services0% coinsurance35% coinsuranceIf you are pregnantChildbirth/delivery facility services(c)2021 Aetna Inc.15.02.931.1-AZ A35% coinsurance,15% coinsurance,after 150after 75 copay/staycopay/stayLimitations, Exceptions, & Other ImportantInformationNoneNoneNo coverage for non-emergency use.NoneNo coverage for non-urgent use.Penalty of 500 for failure to obtain preauthorization for out-of-network care.NoneNonePenalty of 500 for failure to obtain pre authorization for out-of-network care.Cost sharing does not apply for preventiveservices. Maternity care may include tests andservices described elsewhere in the SBC (i.e.ultrasound.) Penalty of 500 for failure to obtainpre-authorization for out-of-network care mayapply.002021-002021-003479Page 3 of 6

Common MedicalEventServices You May NeedHome health careRehabilitation servicesHabilitation servicesIf you need helprecovering or have Skilled nursing careother specialhealth needsDurable medical equipmentHospice servicesIf your child needsdental or eye careWhat You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most)15% coinsurance35% coinsurance15% coinsurance35% coinsurance15% coinsurance35% coinsurance35% coinsurance,15% coinsurance,after 150after 75 copay/staycopay/stay15% coinsurance35% coinsurance15% coinsurance35% coinsuranceChildren's eye examNo chargeChildren's glassesNo chargeChildren's dental check-upNo charge30% coinsurance,deductible doesn’tapply30% coinsurance,deductible doesn’tapply30% coinsuranceLimitations, Exceptions, & Other ImportantInformationNoneIncludes Physical, Occupational & SpeechTherapy.Penalty of 500 for failure to obtain pre authorization for out-of-network care.Limited to 1 durable medical equipment forsame/similar purpose. Excludes repairs formisuse/abuse.Penalty of 500 for failure to obtain pre authorization for out-of-network care.1 routine eye exam/plan year. Covered throughthe end of the month in which the covered personturns 19.1 pair of glasses or lenses/plan year. Coveredthrough the end of the month in which thecovered person turns 19.Covered through the end of the month in whichthe covered person turns 19.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.) AcupunctureCosmetic surgery(c)2021 Aetna Inc.15.02.931.1-AZ A Dental care (Adult)Long-term care Routine foot careWeight loss programs - Except for required preventiveservices.002021-002021-003479Page 4 of 6

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric surgeryChiropractic careHearing aids - 1 hearing aid per ear/plan year. Infertility treatment - Limited to the diagnosis& treatment of underlying medical condition.Non-emergency care when traveling outsidethe U.S. Private-duty nursingRoutine eye care (Adult) – 1 routine eye exam/plan year.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: Arizona Department of Insurance andFinancial Institutions, 800-325-2548, 602-364-2499 (Phoenix), 602-364-2977 (Spanish), https://insurance.az.gov/consumers. For more information on your rights to continue coverage, contact the plan at 1-800-927-0783.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 informationabout your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit aclaim, appeal, or a grievance 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 1-800-927-0783. Arizona Department of Insurance and Financial Institutions, 800-325-2548, 602-364-2499 (Phoenix), 602-364-2977 (Spanish), https://insurance.az.gov/consumers.Does this plan provide Minimum Essential Coverage? Yes.Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.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.(c)2021 Aetna Inc.15.02.931.1-AZ A002021-002021-003479Page 5 of 6