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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesAllegiance: MUS Choices Employee Benefit PlanCoverage Period: 07/01/2019 – 06/30/2020Coverage for: Individual/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 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 costs, visit www.choices.mus.edu or call 1-877-501-1722. For general definitions of commonterms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, visitwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-877-501-1722 to request a copy.Important QuestionsWhat is the overalldeductible?Answers 750/Individual or 1,500/FamilyIn-NetworkWhy This Matters:You must pay all of the costs from providers up to the deductible amount before the plan beginsto pay for these services. Deductible applies to all services, unless otherwise indicated, or acopayment applies.Are there servicescovered before you meetyour deductible?Yes. Preventive care, primary care,and specialist office visit servicesare covered before you meet yourdeductible.The plan covers some services even if you haven’t yet met the deductible amount. But acopayment or coinsurance may apply. For example, this plan covers certain preventiveservices without cost-sharing and before you meet your deductible. See a list of coveredpreventive services at e-benefits/.Are there otherdeductibles for specificservices? 750/Individual or 1,750/FamilyOut-of-NetworkYou must pay all of the costs from out-of-network providers up to the deductible amount beforethe plan begins to pay for these services.What is the out-of-pocketlimit for this plan? 4,000/Individual or 8,000/FamilyIn-Network 6,000/Individual or 12,000/FamilyOut-of-NetworkThe out-of-pocket limit is the most you could pay in a benefit period for covered services. If youhave other family members in this plan, they have to meet their own out-of-pocket limits untilthe overall family out-of-pocket limit has been met.What is not included inthe out-of-pocket limit?Premiums, balance-billing charges,and health care this plan doesn’tcover.Even though you pay these expenses, they don’t count toward the out–of–pocket limit.Will you pay less if youuse a network provider?Yes.Visit www.abpmtpa.com/mus or call1-877-778-8600 for a list of networkproviders.You will pay less if you use a network provider. You will pay the most if you use an out-ofnetwork provider, and you might receive a bill from a provider for the difference between theprovider’s charge and what your plan pays (balance billing). Be aware, your network providermight use an out-of-network provider for some services (such as lab work). Check with yourprovider before you get services.Do you need a referral tosee a specialist?No.You can see a specialist without a referral or permission from the plan.1 of 8

All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventServices You May NeedPrimary Care Provider (PCP)office visit to treat an injury orillness, includes Naturopathic.If you visit a healthcare provider’s officeor clinicSpecialist office visitPreventive care/screening/ImmunizationDiagnostic test (x-ray, bloodwork)If you have a testImaging (CT/PET scans, MRIs)What You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most) 25 copay/office visit;35% coinsurance;25% coinsurance fordeductible appliesother outpatientservices; deductibleapplies 40 copay/office visit;35% coinsurance;25% coinsurance fordeductible appliesother outpatientservices; deductibleapplies0%35% coinsurance;deductible applies25% coinsurance;deductible applies35% coinsurance;deductible applies25% coinsurance;deductible applies35% coinsurance;deductible appliesRetail(34-day supply)If you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available atwww.navitus.com .Limitations, Exceptions, & Other ImportantInformationOffice visit limited to evaluation andmanagement charges. All other charges aresubject to deductible and coinsurance.Naturopathic services- You may beresponsible for balance billing.Office visit limited to evaluation andmanagement charges.All other charges are subject to deductible andcoinsurance.You may have to pay for services that aren’tpreventive. Ask your provider if the servicesyou need are preventive. Then check whatyour plan will pay for.May require prior authorization.Retail or Mail Order(90-day supply)Certain Preventive Drugs(Tier 0) 0 copay 0 copayPreferred brand drugs(Tier 1)(Tier 2) 15 copay 50 copay 30 copay 100 copayCovers up to a 34-day supply (retailprescription); 90-day supply (retail or mailorder prescription).2 of 8

CommonMedical EventServices You May NeedNon-preferred brand drugs(Tier 3)Specialty drugs (Tier 4)What You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)50% coinsurance50% coinsurance 200 copay (preferredspecialty pharmacy)50% coinsurance (retailor out-of-networkpharmacy)50% coinsurance does not apply to annualprescription out-of-pocket limit.Out-of-Pocket Limit 2,150/Individual or 4,300/FamilyIf you have outpatientsurgeryFacility fee (e.g., ambulatorysurgery center)Physician/surgeon feesEmergency Room careIf you need immediatemedical attentionEmergency medicaltransportationUrgent CareLimitations, Exceptions, & Other ImportantInformation25% coinsurance;deductible applies35% coinsurance;deductible applies25% coinsurance;deductible applies35% coinsurance;deductible applies 250 copay/visit; 25%coinsurance for otheroutpatient services;deductible applies 200 copay/transport 250 copay/visit; 25%coinsurance for otheroutpatient services;deductible applies 200 copay/transport 75 copay/visit; 25%coinsurance for otheroutpatient services;deductible applies 75 copay/visit; 25%coinsurance for otheroutpatient services;deductible applies.All other charges are subject to deductible andcoinsurance.Office visit limited to evaluation andmanagement charges. All other charges aresubject to deductible and coinsurance.3 of 8

CommonMedical EventWhat You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)25% coinsurance;35% coinsurance;Facility fee (e.g., hospital room) deductible appliesdeductible appliesServices You May NeedIf you have a hospitalstayPhysician/surgeon feesIf you need mentalhealth or chemicaldependency servicesOffice visitsChildbirth/delivery professionalservicesChildbirth/delivery facilityservicesHome Health CareIf you need helprecovering or haveother special healthneeds35% coinsurance;deductible applies1st 4 visits at 0, then 25 copay/visit35% coinsurance;deductible appliesPsychiatrist- 40copay/visit25% coinsurance;deductible applies35% coinsurance;deductible appliesOutpatient servicesInpatient servicesIf you are pregnant25% coinsurance;deductible appliesOutpatient Rehabilitativeservices visit- physical, speech,occupational, pulmonary,cardiac, respiratory, andmedical massage therapies;chiropractic; acupunctureInpatient Rehabilitativeservices 25 copay/visit35% coinsurance;deductible applies25% coinsurance;deductible applies35% coinsurance;deductible applies25% coinsurance;deductible applies35% coinsurance;deductible applies 25 copay/visit35% coinsurance;deductible applies 25 copay/visit35% coinsurance;deductible appliesLimitations, Exceptions, & Other ImportantInformation1st 4 visits at 0 copay/visit- mental health andchemical dependency combined visits(excludes psychiatrist).Prior authorization is recommended/max 30visits/year.Outpatient maximum 30 visits/year- alloutpatient rehabilitative services combined.Massage therapy and Acupuncture servicesYou may be responsible for balance billing.25% coinsurance;deductible applies35% coinsurance;deductible appliesInpatient maximum 30 days/year.4 of 8

CommonMedical EventServices You May NeedLimitations, Exceptions, & Other ImportantInformationPrior authorization is recommended/max 30days/year.Skilled Nursing Facility25% coinsurance;deductible applies35% coinsurance;deductible appliesDurable Medical Equipment25% coinsurance;deductible applies35% coinsurance;deductible applies25% coinsurance;deductible applies35% coinsurance;deductible appliesMaximum is 6 months.Hospice services0%35% coinsurance;deductible appliesLimited to one exam per year (routine ormedical).Eye exam***covered by medical planIf you need dental oreye careWhat You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Up to 300- 1 pair of eyeglass frames andlenses, in lieu of contact lenses/year.Optional Vision Hardware*** BCBSMTDental*** Delta DentalFee schedule payment.Fee schedule payment.Up to 150- 1 purchase of contact lenses, inlieu of eyeglass frames and lenses/year.Basic Plan covers up to 750/individual.Select Plan covers up to 1,500/individual.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 Surgery Hearing Aids Work related accident/illness Infertility Treatment Private Duty Nursing Routine Foot CareOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture Chiropractic Care Medically necessary travel with priorauthorization- 1,500 max/year Organ transplant Preventive Services5 of 8