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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Servicesshow here]Regence BlueShield: Regence EmployeeChoice Gold 2500 PreferredCoverage Period: [When enrolled, the coverage period willCoverage for: Individual and Eligible Family 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 share thecost 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 coverage, go toregence.com/go/2020/booklet/WW/Gold2500 or call 1 (888) 367-2112. For general definitions of common terms, such as allowed amount, balance billing, coinsurance,copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1 (888) 367-2112 to requesta copy.Important QuestionsWhat is the overalldeductible?AnswersIn-network: 2,500 individual / 5,000 family percalendar year.Out-of-network: 5,000 individual / 10,000family per calendar year.Are there services coveredbefore you meet yourdeductible?Yes. Certain preventive care and those serviceslisted below as "deductible does not apply" or as"No charge."Are there other deductiblesfor specific services?No.What is the out-of-pocketlimit for this plan?What is not included in theout-of-pocket limit?In-network: 7,350 individual / 14,700 familyper calendar year.Out-of-network: 10,000 individual / 20,000family per calendar year.Premiums, balance-billed charges, and healthcare this plan doesn't cover.Why This Matters:Generally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay. If you have other family members on the plan, eachfamily member must meet their own individual deductible until the total amount ofdeductible expenses paid by all family members meets the overall family deductible.This plan covers some items and services even if you haven't yet met thedeductible amount. But a copayment or coinsurance may apply. For example,this plan covers certain preventive services without cost sharing and beforeyou meet your deductible. See a list of covered preventive services /.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. 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.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use anetwork provider?Yes. See regence.com/go/WW/Preferred or call1 (888) 367-2112 for a list of 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 andwhat your plan pays (balance billing). Be aware, your network provider might use anout-of-network provider for some services (such as lab work). Check with yourprovider before you get services.Do you need a referral to seea specialist?No.You can see the specialist you choose without a referral.1 of 7[When enrolled, the group name will show here]WW0120SGLD25SD

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 treatan injury or illnessIf you visit a healthcare provider's officeor clinicSpecialist visitWhat You Will PayIn-network ProviderOut-of-network Provider(You will pay the least)(You will pay the most) 30 copay / office visit 20 copay / office visit at aretail clinicDeductible does not apply50% coinsurancefor these visits30% coinsurance for allother services 50 copay / visitDeductible does not applyfor these visitsLimitations, Exceptions, & Other ImportantInformationCoverage includes primary care visits at a retail clinic.In-network acupuncture and spinal manipulations aresubject to 30 copay / visit, deductible does not apply.Acupuncture services are limited to 12 visits / year.Spinal manipulations are limited to 10 / year.50% coinsurance30% coinsurance for allother servicesIf you have a c test (x-ray,blood work)Imaging (CT/PET scans,MRIs)No charge50% coinsurance30% coinsurance,deductible does not apply50% coinsurance30% coinsurance50% coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services neededare preventive. Then check what your plan will pay for.None2 of 7

Common MedicalEventServices You May NeedPreferred generic drugs &generic drugsPreferred brand drugsIf you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available atregence.com/go/druglist/2020/WW/6tier.Brand drugsPreferred specialty drugs& specialty drugsFacility fee (e.g.,ambulatory surgerycenter)If you have outpatientsurgeryPhysician/surgeon feesWhat You Will PayIn-network ProviderOut-of-network Provider(You will pay the least)(You will pay the most) 10 copay* / preferred generic retail prescription 20 copay / preferred generic mail order prescription25% coinsurance* / generic retail prescription20% coinsurance / generic mail order prescription 50 copay* / retail prescription 100 copay / mail order prescription50% coinsurance* / retail prescription45% coinsurance / mail order prescription20% coinsurance / preferred specialty drugs50% coinsurance / specialty drugs20% coinsurance forambulatory surgery centers;30% coinsurance for allother facilities20% coinsurance forambulatory surgery centerphysicians;30% coinsurance for allother physiciansLimitations, Exceptions, & Other ImportantInformationNo coverage for prescription drugs not on the Drug Listor prescription drugs from an out-of-network pharmacy.Limited to a 90-day supply retail (1 copay per 30-daysupply), mail order and self-injectable drugs.Limited to a 30-day supply specialty drugs (includingpreferred) and self-administrable cancer chemotherapydrugs.Deductible does not apply for all prescription drugs.No charge for FDA-approved women's contraceptivesprescribed by a health care provider and for certainpreventive drugs and immunizations at a participatingpharmacy.The first fill for specialty drugs (including preferred)may be provided at a retail pharmacy, additional fillsand fills for specialty self-administrable cancerchemotherapy drugs must be provided at a specialtypharmacy.Coverage for self-administrable cancer chemotherapydrugs is subject to 30% coinsurance.* 5 copayment or 5% coinsurance discount when filledat a preferred retail pharmacy.50% coinsuranceNone50% coinsuranceNone3 of 7

Common MedicalEventIf you need immediatemedical attentionIf you have a hospitalstayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesIf you are pregnantServices You May NeedWhat You Will PayIn-network ProviderOut-of-network Provider(You will pay the least)(You will pay the most)Emergency room care30% coinsurance after 300copay / visit30% coinsurance after 300 copay / visitEmergency medicaltransportation30% coinsurance30% coinsuranceUrgent care 50 copay / visit, deductibledoes not apply; otherservices 30% coinsurance50% coinsurance30% coinsurance50% coinsurance30% coinsurance 30 copay / visit, deductibledoes not apply; otherservices 30% coinsurance50% coinsuranceInpatient services30% coinsurance50% coinsuranceOffice visitsChildbirth/deliveryprofessional services30% coinsurance50% coinsurance30% coinsurance50% coinsurance30% coinsurance50% coinsuranceFacility fee (e.g., hospitalroom)Physician/surgeon feesOutpatient servicesChildbirth/delivery facilityservices50% coinsuranceLimitations, Exceptions, & Other ImportantInformationCopayment applies to the facility charge for each visit(waived if admitted), whether or not the in-networkdeductible has been met.In-network deductible applies to in-network and out-ofnetwork services.Copayment applies to each in-network urgent care visitonly.Limited to 3,500 / day for inpatient non-emergencyadmissions in out-of-network facilities.NoneCopayment applies to each in-network office visit andpsychotherapy only.Limited to 3,500 / day for inpatient non-emergencyadmissions in out-of-network facilities.Cost sharing does not apply to certain preventiveservices. Depending on the type of services, acoinsurance or deductible may apply. Maternity caremay include tests and services described elsewhere inthe SBC (i.e. ultrasound).Limited to 3,500 / day for inpatient non-emergencyadmissions in out-of-network facilities.4 of 7

Common MedicalEventServices You May NeedHome health careIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careWhat You Will PayIn-network ProviderOut-of-network Provider(You will pay the least)(You will pay the most)30% coinsurance50% coinsuranceLimitations, Exceptions, & Other ImportantInformationRehabilitation servicesInpatient: 30% coinsuranceOutpatient: 30 copay /visit, deductible does notapply50% coinsuranceHabilitation servicesInpatient: 30% coinsuranceOutpatient: 30 copay /visit, deductible does notapply50% coinsuranceSkilled nursing careDurable medicalequipmentHospice services30% coinsurance50% coinsuranceLimited to 130 visits / year.Inpatient is limited to 30 days / year.Outpatient is limited to 25 visits / year. Copaymentapplies to each in-network outpatient visit only.Limited to 3,500 / day for inpatient non-emergencyadmissions in out-of-network facilities.Inpatient habilitative services is limited to 30 days /year.Outpatient habilitative services is limited to 25 visits /year.Neurodevelopmental therapy is subject to deductibleand coinsurance; outpatient is limited to 25 visits /year.Limited to 3,500 / day for inpatient non-emergencyadmissions in out-of-network facilities.Limited to 60 inpatient days / year.30% coinsurance50% coinsuranceNone30% coinsurance50% coinsuranceChildren's eye examNo charge50% coinsuranceChildren's glassesNo charge50% coinsuranceChildren's dental checkupNo chargeNo chargeLimited to 14 respite days / lifetime.Limited to 1 routine exam / year for individuals underage 19.Limited to 1 pair of lenses (2 lenses) and 1 standardframe / year for individuals under age 19.Limited to 2 cleanings and 2 preventive oralexaminations / year for individuals under age 19.Additional coverage is provided for basic and majorpediatric dental services.5 of 7