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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesUNIVERSITY OF SAN DIEGO:OA Managed Choice POSCoverage Period: 08/01/2021-07/31/2022Coverage for: Individual Plan Type: POSThe 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 calling1-866-746-6590. 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 1-866-746-6590 to request a copy.Important QuestionsWhat is the overalldeductible?AnswersFor each Plan Year, In-Network: Individual 300. Out-of-Network: Individual 600.Are there services coveredbefore you meet yourdeductible?Yes. In-network primary care office visits,inpatient hospital services, prescription drugs &preventive care are covered before you meetyour 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?Yes. For prescription drugs - Individual 100.There are no other specific deductibles.In-Network: Individual 7,900. Out-of-Network:Individual 12,700.Premiums, balance-billing charges, health carethis plan doesn't cover & penalties for failure toobtain precertification for services.Will you pay less if you use anetwork provider?Yes. See www.aetna.com/docfind or call 1-866 746-6590 for a list of in-network providers.Do you need a referral to seea specialist?Yes.SBC 2122 UNIVERSITY OF SAN DIEGO 002021-002021-000603Why 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 don’t have to meet deductibles for specific 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.This plan will pay some or all of the costs to see a specialist for covered services butonly if have a referral before you see the specialist.Page 1 of 7

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 illnessIf you visit a health Specialist visitcare provider’soffice or clinicWhat You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most)Limitations, Exceptions, & Other ImportantInformation 20 copay/visit,deductible doesn'tapply35% coinsuranceNone 20 copay/visit,deductible doesn'tapply35% coinsuranceNonePreventive care /screening /immunizationNo charge35% coinsuranceYou may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for.Diagnostic test (x-ray, blood work)20% coinsurance35% coinsuranceNoneImaging (CT/PET scans, MRIs)20% coinsurance35% coinsuranceNoneIf you have a testSBC 2122 UNIVERSITY OF SAN DIEGO 002021-002021-000603Page 2 of 7

Common MedicalEventIf you need drugsto treat yourillness orconditionMore informationabout prescriptiondrug coverage isavailable athttps://www.aetna.com/individuals families/pharmacy.htmlServices You May NeedGeneric drugsPreferred brand drugsNon-preferred brand drugsSpecialty drugsIf you haveoutpatient surgeryFacility fee (e.g., ambulatory surgery center)Physician/surgeon feesEmergency room careIf you needimmediate medical Emergency medical transportationattentionUrgent careIf you have ahospital stayWhat You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most)Copay/prescription,after specificdeductible: 15Not covered(retail), 37.50 (mailorder)Copay/prescription,after specificdeductible: 40Not covered(retail), 100 (mailorder)Copay/prescription,after specificNot covereddeductible: 65(retail), 162.50(mail order)Applicable cost asnoted above forNot coveredgeneric or branddrugs20% coinsurance35% coinsurance20% coinsurance35% coinsurance20% coinsurance20% coinsuranceafter 150after 150copay/visitcopay/visit20% coinsurance20% coinsurance 20 copay/visit,deductible doesn't35% coinsuranceapplyFacility fee (e.g., hospital room)20% coinsurance35% coinsurancePhysician/surgeon fees20% coinsurance35% coinsuranceSBC 2122 UNIVERSITY OF SAN DIEGO 002021-002021-000603Limitations, Exceptions, & Other ImportantInformationCovers 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.NoneNoneNoneNo coverage for non-emergency use.NoneNo coverage for non-urgent use.Penalty of 500 for failure to obtainprecertification for out-of-network care.NonePage 3 of 7

Common MedicalEventIf you need mentalhealth, behavioralhealth, orsubstance abuseservicesIf you are pregnantServices You May NeedOutpatient servicesInpatient services20% coinsurance35% coinsuranceOffice visitsChildbirth/delivery professional servicesNo charge20% coinsurance35% coinsurance35% coinsuranceChildbirth/delivery facility services20% coinsurance35% coinsuranceHome health careRehabilitation servicesHabilitation services20% coinsurance20% coinsurance20% coinsurance35% coinsurance35% coinsurance35% coinsurance20% coinsurance35% coinsurance20% coinsurance35% coinsuranceHospice services20% coinsurance35% coinsuranceChildren's eye examNo chargeChildren's glassesNo chargeChildren's dental check-upNo chargeIf you need helprecovering or have Skilled nursing careother specialhealth needsDurable medical equipmentIf your child needsdental or eye careWhat You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most)Office: 20copay/visit,Office & otherdeductible doesn'toutpatient services:apply; other35% coinsuranceoutpatient services:20% coinsuranceSBC 2122 UNIVERSITY OF SAN DIEGO 002021-002021-00060330% coinsurance,deductible doesn'tapply30% coinsurance,deductible doesn'tapply30% coinsuranceLimitations, Exceptions, & Other ImportantInformationNonePenalty of 500 for failure to obtainprecertification 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 obtainprecertification for out-of-network care mayapply.NoneIncludes Physical, Occupational & SpeechTherapy.Penalty of 500 for failure to obtainprecertification for out-of-network care.Limited to 1 durable medical equipment forsame/similar purpose. Excludes repairs formisuse/abuse.Penalty of 500 for failure to obtainprecertification for out-of-network care.1 routine eye exam/plan year up to age 19.1 pair of glasses or lenses/plan year.NonePage 4 of 7

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.) Cosmetic surgeryDental care (Adult)Hearing aids Long-term carePrivate-duty nursing Routine foot careWeight loss programs - Except for required preventiveservices.Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) AcupunctureBariatric surgeryChiropractic care Infertility treatment - Limited to the diagnosis& treatment of underlying medical condition.Non-emergency care when traveling outsidethe U.S. Routine 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: California Department of Insurance,Consumer Communications Bureau Health, 300 South Spring Street, South Tower, Los Angeles, CA 90013, 1-800-927-HELP (4357), 1-800-482-4833 (TYY),http://www.insurance.ca.gov. For more information on your rights to continue coverage, contact the plan at 1-866-746-6590.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 1-866-746-6590. California Department of Insurance, Consumer Communications Bureau Health Unit, 300 South Spring Street, South Tower, Los Angeles, CA 90013, 1-800-927 HELP (4357), 1-800-482-4833 (TYY), http://www.insurance.ca.gov. Additionally, a consumer assistance program can help you file your appeal. Contact California Department of Insurance, Consumer Communications Bureau, 300South Spring Street, South Tower, Los Angeles, CA 90013, 1-800-927-Help (4357), 1-800-482-4833(TTY), www.insurance.ca.govDoes 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.SBC 2122 UNIVERSITY OF SAN DIEGO 002021-002021-000603Page 5 of 7

To see examples of how this plan might cover costs for a sample medical situation, see the next section.SBC 2122 UNIVERSITY OF SAN DIEGO 002021-002021-000603Page 6 of 7