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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 01/01/2020 – 12/31/2020SAMBA Health Benefit Plan: Standard OptionCoverage for: Self Only, Self Plus One or Self and 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. Please read the FEHB Plan brochure (RI 71-015) that contains the complete terms of this plan. All benefits are subject to the definitions,limitations, and exclusions set forth in the FEHB Plan brochure. Benefits may vary if you have other coverage, such as Medicare. For general definitions ofcommon terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can get theFEHB Plan brochure at www.SambaPlans.com, and view the Glossary at www.SambaPlans.com/health-benefit-plan/sbc/. You can call 1-800-638-6589 to request acopy of either document.Important QuestionsAnswersYes. Prescription drugs, inpatienthospital and preventive care you receivefrom a PPO providerWhy This Matters:Generally, you must pay all of the costs from providers up to the deductible amount beforethis plan begins to pay. Copayments and coinsurance amounts do not count toward yourdeductible, which generally starts over January 1. When a covered service/supply is subjectto a deductible, only the Plan allowance for the service/supply counts toward the deductible.If you have other family members on the plan, each family member must meet their ownindividual deductible until the total amount of deductible expenses paid by all family membersmeets the overall family deductible.This plan covers some items and services even if you haven’t yet met the deductible amount.But a copayment 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/.What is the overalldeductible?PPO providers: 350/Self Only; 700/Self Plus One; 900/Self and FamilyNon-PPO providers: 350/Self Only; 700/ Self Plus One; 900/Self and FamilyNoYou don’t have to meet deductibles for specific services.What is the out-ofpocket limit for thisplan?PPO providers: 7,000 Self Only; 14,000 Self Plus One and Self & FamilyNon-PPO providers: 9,500 Self Only; 19,000 Self Plus One and Self & FamilyThe out-of-pocket limit, or catastrophic maximum, is the most you could pay in a year forcovered services. If you have other family members in this plan, they have to meet their ownout-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included inthe out-of-pocket limit?Premiums, balance-billed charges,penalties for failure to get prior approval,and expenses this plan doesn’t coverEven though you pay these expenses, they don’t count toward the out–of–pocket limit.Are there servicescovered before youmeet your deductible?Are there otherdeductibles for specificservices?Yes. See www.SambaPlans.com or callWill you pay less if you1-800-638-6589 for a list of networkuse a network provider?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 might receive abill from a provider for the difference between the provider’s charge and what your plan pays(balance billing). Be aware, your network provider might use an out-of-network provider forsome services (such as lab work). Check with your provider before you get services.Do you need a referralto see a specialist?You can see the specialist you choose without a referral.No.1 of 7

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 healthcare provider’s officeor clinicIf you have a testPrimary care visit to treat aninjury or illnessWhat You Will PayOut-of-Network ProviderNetwork Provider(You will pay the most,plus you may be(You will pay the least)balance billed) 20 copay/visit;deductible does not apply 45% coinsuranceSpecialist visit 30 copay/visit;deductible does not applyServices You May Need45% coinsurancePreventive care/screening/immunizationNo charge45% coinsuranceDiagnostic test (x-ray, bloodwork)20% coinsurance45% coinsuranceImaging (CT/PET scans, MRIs)20% coinsurance45% coinsuranceGeneric drugsRetail: 12 copay( 7 copay if Medicare PartB primary)Mail: 20 copay( 15 copay if MedicarePart B primary)Preferred brand drugsRetail: 35% coinsurance(30% coinsurance ifMedicare Part B primary), 150 max.Mail: 35% coinsurance(30% coinsurance ifMedicare Part B primary), 300 max.If you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available atwww.SambaPlans.comLimitations, Exceptions, & Other ImportantInformationNo referral is needed.You may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for.Quest Labs & LabCorp outpatient services arepaid at 100%.Prior authorization is required. If you do notget prior authorization, we will reduce ourallowance by 20%.Retail: 12 copay( 7 copay if Medicare PartB primary)Mail: 20 copay( 15 copay if MedicarePart B primary)No deductiblePlus the difference in costRetail purchases are limited to initial fill, up to ahad you used an in30-day supply, and one refill.network pharmacyMail order is limited to a 90-day supply.Retail: 35% coinsurance(30% coinsurance ifA 90-day supply of maintenance drugs can beMedicare Part B primary), purchased at select participating retail 150 max.pharmacies through Express Scripts Smart90 Mail: 35% coinsuranceProgram; see page 74 of the Plan brochure.(30% coinsurance ifMedicare Part B primary), 300 max.Plus the difference in costhad you used an innetwork pharmacyFor more information about limitations and exceptions, see the FEHB Plan brochure RI 71-015 at www.SambaPlans.com.2 of 7

CommonMedical EventIf you have outpatientsurgeryIf you need immediatemedical attentionIf you have a hospitalstayServices You May NeedWhat You Will PayOut-of-Network ProviderNetwork Provider(You will pay the most,plus you may be(You will pay the least)balance billed)Retail: 50% coinsurance, 300 max.Mail: 50% coinsurance, 600 max.Plus difference in costhad you used an innetwork pharmacyNon-preferred brand drugsRetail: 50% coinsurance, 300 max.Mail: 50% coinsurance, 600 max.Specialty drugsGeneric/Preferred: 35%coinsurance, 240 max.Non-Preferred: 50%coinsurance, 480 max.Not coveredFacility fee (e.g., ambulatorysurgery center)20% coinsurance45% coinsurancePhysician/surgeon fees20% coinsurance45% coinsuranceEmergency room care20% coinsurance20% coinsuranceEmergency medicaltransportation20% coinsurance45% coinsuranceUrgent care20% coinsurance45% coinsurance 200 copay/confinementFacility fee (e.g., hospital room) Nothing for room & board;20% coinsurance for otherhospital chargesPhysician/surgeon fees20% coinsuranceLimitations, Exceptions, & Other ImportantInformationLimited to a 30-day supply.Requires prior authorization.Must be obtained through Accredo.Some services require prior authorization. Ifyou do not get prior authorization, we willreduce our allowance by 20%.Covered services rendered within 24 hours ofan accidental injury are paid in full. 400 copay/confinement45% coinsurance for room Prior authorization is required; 500 penalty forfailure to get prior approval.& board and otherhospital charges45% coinsuranceSome services require prior authorization. Ifyou do not get prior authorization, we willreduce our allowance by 20%.For more information about limitations and exceptions, see the FEHB Plan brochure RI 71-015 at www.SambaPlans.com.3 of 7

CommonMedical EventIf you need mentalhealth, behavioralhealth, or substanceabuse servicesServices You May NeedOutpatient servicesWhat You Will PayOut-of-Network Provider Limitations, Exceptions, & Other ImportantNetwork Provider(You will pay the most,Informationplus you may be(You will pay the least)balance billed) 30 copay/office visitSome services require prior authorization. Ifyou do not get prior authorization, we will20% coinsurance for other 45% coinsurancereduce our allowance by 20%.servicesInpatient services 200 copay/confinementNothing for room & board;20% coinsurance for otherhospital charges 400 copay/confinement45% coinsurance for room Prior authorization is required; 500 penalty forfailure to get prior approval.& board and otherhospital chargesOffice visits 30 copay/visit45% coinsuranceChildbirth/delivery professionalservicesNo charge45% coinsuranceChildbirth/delivery facilityservicesNo charge 400 copay/confinement45% coinsurance for room No prior authorization needed.& board and otherhospital chargesHome health care20% coinsuranceRehabilitation services20% coinsuranceHabilitation services20% coinsuranceSkilled nursing careIf you are pregnantIf you need helprecovering or haveother special healthneeds50% coinsurancePhysical/occupationaltherapy: 50% coinsuranceSpeech therapy: 45%coinsurancePhysical/occupationaltherapy: 50% coinsuranceSpeech therapy: 45%coinsuranceLimited to 25 visits per calendar year.Physical/occupational therapy limited to 50visits per yearSpeech therapy requires prior authorizationand is limited to 30 visits per yearPhysical/occupational therapy limited to 50visits per yearSpeech therapy requires prior authorizationand is limited to 30 visits per year20% coinsurance45% coinsuranceFacility care limited to 30 days per yearDurable medical equipment20% coinsurance50% coinsuranceHospice services20% coinsurance45% coinsuranceInpatient care limited to 14 days per yearOutpatient care limited to 15,000For more information about limitations and exceptions, see the FEHB Plan brochure RI 71-015 at www.SambaPlans.com.4 of 7