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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services: The Ohio State University 2020-1098-1Coverage Period: 07/21/2020 - 08/17/2021Coverage for: Student/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 to get a copy of the complete terms of coverage, visit www.uhcsr.com/osu or call(844) 206-0374. For general definitions of common terms, such as allowed amount, balance billing, coinsurance (coins), copayment (copay), deductible (ded),provider, or other underlined terms see the Glossary. You can view the Glossary at www.cciio.cms.gov or call (844) 206-0374 to request a copy.Important QuestionsWhat is the overalldeductible?Are there services coveredbefore you meet yourdeductible?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 usea network provider?Do you need a referral tosee a specialist?AnswersOhio State Network Providers / UHC OptionsProviders outside Franklin Co: 150 (Person), 350 (Family) UHC Options Providers insideFranklin Co: 500 (Person), 1,500 (Family)Out of Network: 500 (Person), 1,500(Family)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, each familymember must meet their own individual deductible until the total amount of deductibleexpenses paid by all family members meets the overall family deductible.This plan covers some items and services even if you haven’t yet met the deductibleYes. Preventive care, Pediatric Dental,amount. But a copayment or coinsurance may apply. For example, this plan coversPediatric Vision and Prescription Drugs arecertain preventive services without cost sharing and before you meet your deductible.covered before you meet your deductible.See a list of covered preventive services are-benefits/.Yes. Pediatric Dental 500. There are no other You must pay all of the costs for these services up to the specific deductible amountspecific deductibles.before this plan begins to pay for these services.Ohio State Network Providers / UHC OptionsProviders outside Franklin Co: 2,700The out-of-pocket limit is the most you could pay in a year for covered services. If you(Person), 5,400 (Family) UHC Optionshave other family members in this plan, they have to meet their own out-of-pocket limitsProviders inside Franklin Co: 6,000 (Person),until the overall family out-of-pocket limit has been met. 12,000 (Family) Out of Network: 6,000(Person), 12,000 (Family)Premiums, balance-billing charges, and healthEven though you pay these expenses, they don’t count toward the out–of–pocket limit.care this plan doesn’t cover.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 mightYes. See www.uhcsr.com/osu or call (844)receive a bill from a provider for the difference between the provider’s charge and what206-0374 for a list of network providers.your plan pays (balance billing). Be aware your network provider might use an out-ofnetwork provider for some services (such as lab work). Check with your provider beforeyou get services.No.You can see the specialist you choose without a referral.1 of 8

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedPrimary care visit to treat an injury or illnessIf you visit a health careprovider’s office orclinicSpecialist visitPreventive care/screening/immunizationDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs)HealthSmart RXIf you have a testIf you need drugs totreat your illness orconditionGeneric drugsMore information about Preferred brand drugsprescription drugcoverage is available atwww.uhcsr.com/pdlNon-preferred brand drugsLimitations, Exceptions, & OtherPreferredOut-of-NetworkImportant InformationProvider (You In-Network Provider (Youwill pay theProviderwill pay theleast)most) 20 Copay pervisit; ded does 40% Coins40% Coinsnot applyMay not apply when related to surgery orPhysiotherapy. 20 Copay pervisit; ded does 40% Coins40% Coinsnot applyIncludes preventive services specified inthe health care reform law or benefitsprovided as mandated by state law.No ChargeNo Charge40% CoinsYou may have to pay for services thataren’t preventive. Ask your provider if theservices needed are preventive. Thencheck what your plan will pay for.10% Coins40% Coins40% �––––––––10% Coins40% Coins40% �––––––––10% Coinsded does notapply10% Coins10% Coinsded does not ded does notapplyapply20% Coinsded does notapply20% Coins50% Coinsded does not ded does notapplyapply50% Coinsded does notapply50% Coins50% Coinsded does not ded does notapplyapplyMinimum cost to the insured is 10 or thecost of the drug, whichever is less.Limited up to a 31 day supply perprescription.Minimum cost to the insured is 10 or thecost of the drug, whichever is less.Limited up to a 31 day supply perprescription.Minimum cost to the insured is 10 or thecost of the drug, whichever is less.*For more information about limitations and exceptions, see plan or policy document at www.uhcsr.com/osu2 of 8

What You Will PayCommon Medical EventServices You May NeedSpecialty drugsIf you have outpatientsurgeryFacility fee (e.g., ambulatory surgery center)Physician/surgeon feesEmergency room careIf you need immediatemedical attentionEmergency medical transportationUrgent careIf you have a hospitalstayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesFacility fee (e.g., hospital room)Physician/surgeon feesOutpatient servicesInpatient servicesPreferredOut-of-NetworkProvider (You In-Network Provider (Youwill pay theProviderwill pay theleast)most)Limitations, Exceptions, & OtherImportant InformationLimited up to a 31 day supply perprescription.Same asSame asSame as above; Minimum cost to the insured is 40above; dedabove; dedded does notgeneric drug, 80 brand name drug, ordoes not apply does not apply apply 120 non-preferred brand drug, or thecost of the drug, whichever is less.Limited up to a 31 day supply perprescription10% Coins40% Coins40% �––––––––10% Coins40% Coins40% �––––––––10% Coins10% Coins10% CoinsMay be limited to use of emergency room 100 Copay 100 Copay 100 Copay per and supplies.per visit; ded per visit; ded visit; ded does The Copay will be waived if admitted todoes not apply does not apply not applythe Hospital.10% Coins10% Coins10% �–––––––– 25 Copay pervisit; ded does 40% Coins40% CoinsMay be limited to facility fees.not apply10% Coins40% Coins40% �––––––––10% Coins40% Coins40% �––––––––Based onBased onBased on settingsetting where setting where where service �–––––––service isservice isperformedperformedperformedBased onBased onBased on settingsetting where setting where where service �–––––––service isservice isperformedperformedperformed*For more information about limitations and exceptions, see plan or policy document at www.uhcsr.com/osu3 of 8

What You Will PayCommon Medical EventServices You May NeedOffice visitsIf you are pregnantChildbirth/delivery professional servicesChildbirth/delivery facility servicesIf you need helprecovering or haveother special healthneedsPreferredProvider (Youwill pay theleast)Based onsetting whereservice isperformedBased onsetting whereservice isperformedBased onsetting whereservice isperformedHome health care10% CoinsRehabilitation services10% CoinsHabilitation services10% CoinsSkilled nursing careDurable medical equipmentHospice servicesLimitations, Exceptions, & OtherOut-of-NetworkImportant InformationIn-Network Provider (YouProviderwill pay themost)Based onBased on setting Cost sharing does not apply for preventivesetting where where service is services when provided by a Preferredservice isperformedProvider or In-Network Provider.performedDepending on the type of services, aBased onBased on setting copayment, coinsurance, or deductiblesetting where where service is may apply. Maternity care may includetests and services described elsewhere inservice isperformedthe SBC (i.e. ultrasound).performedBased onBased on settingsetting where where service �–––––––service isperformedperformed100 visits maximum per Policy Year /40% Coins40% CoinsAdditional 250 visit maximum per PolicyYear for Private Duty Nursing40% Coins40% CoinsLimits per Policy Year as follows: 20 visits of physical therapy 20 visits of occupational therapy 20 visits of speech therapy 12 visits of manipulative therapy40% Coins40% CoinsSeparate physical, occupational andspeech therapy limits apply toRehabilitative and Habilitative �––––––10% Coins40% Coins40% Coins10% Coins40% Coins40% Coins10% Coins40% Coins40% CoinsSee your50% Coins; 50% Coins; dedIf your child needsplan’s Pediatric ded does not does not apply See your plan’s Pediatric Vision BenefitChildren’s eye examdental or eye careVision Benefit applyDetails. Age limits apply.*Details*For more information about limitations and exceptions, see plan or policy document at www.uhcsr.com/osu4 of 8

What You Will PayCommon Medical EventServices You May NeedChildren’s glassesChildren’s dental check-upPreferredProvider (You In-Networkwill pay theProviderleast)See your50% Coins;plan’s Pediatric ded does notVision Benefit applyDetailsSee your50% Coinsplan’s PediatricDental BenefitDetailsLimitations, Exceptions, & OtherOut-of-NetworkImportant InformationProvider (Youwill pay themost)50% Coins; ded See your plan’s Pediatric Vision Benefitdoes not apply Details. Age limits apply.*50% CoinsSee your plan’s Pediatric Dental BenefitDetails. Age limits apply.**For more information about limitations and exceptions, see plan or policy document at www.uhcsr.com/osu5 of 8