Plan ID 739706

HMO Copay Align HRA

Coverage period: 05.01.2023 to 04.30.2024

Offering the most coverage available before deductible LEPPINK'S INC This document is intended to be an easy-to-read summary to provide a general overview of your benefits. It is not a contract or legal document. Additional limitations and exclusions may apply to covered services. This plan has a specific network of providers, so check the Provider Directory prior to receiving services. Prior authorizations for certain services may apply. A complete description of benefits is contained in the Certificate of Coverage, Schedule or Agreement as applicable. Member cost-sharing Deductible The amount you pay before we begin to pay.

$5,000 individual/$10,000 family Deductible costs don't apply towards your coinsurance maximum. Out-of-network services not covered.

Coinsurance Your share of the costs of a covered health care service.

20% coinsurance for services after deductible is met, except where noted. Out-of-network services not covered.

Coinsurance maximum The most coinsurance cost share you’ll pay for covered services in a contract year. Your coinsurance cost share counts toward your out-of -pocket limit. Out-of-pocket limit The most you’ll pay in a contract year for covered services before we begin to pay 100% of the costs. Office visits

$2,000 individual/$4,000 family

$8,550 individual/$17,100 family

Primary care provider (PCP) $30 copayment, deductible doesn't apply Specialists

$45 copayment, deductible doesn't apply

Urgent care

$75 copayment, deductible doesn't apply

Virtual Care Services For medical and behavioral health visits

Covered in full

Allergy testing, serum and injections

Covered in full

$75 copayment, deductible doesn't apply Retail health clinic Located in a retail center, like a supermarket or pharmacy and provides care for common illnesses and services (examples: ear aches, sore throats, flu shots) Mental and behavioral health Inpatient hospital

20% coinsurance after deductible

Outpatient office visits

$30 copayment, deductible doesn't apply

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Plan ID 739705

Riders Embedded deductible (HSA only)

Oral and non-oral treatments for sexual dysfunction, 50% copay IRS-allowed chronic condition services, supplies and prescription drugs Durable medical equipment Prosthetics and orthotics Minimum Abortion Rider Rehabilitative medicine Chiropractic visits

Includes embedded deductible and embedded TrOOP. The deductible/TrOOP paid by all members will be combined to satisfy the family deductible/TrOOP. One member cannot contribute more than the individual deductible/TrOOP. Deductible $3,000 per member, $6,000 per family per contract year TrOOP $6,000 per member, $12,000 per family per contract year Must be filled by participating pharmacy. These must be authorized. Coverage is limited to: oral tablets, injectable, and intra-urethral. Covers a limited number of medical services, supplies, and medications identified by the IRS as eligible for pre-deductible coverage. Member cost-share still applies. 100% coverage 100% coverage Adds in "abortion coverage in the event of rape or incest" that was removed from the standard medical policy due to the Abortion Opt Out Act 20 additional visits from the standard 30 visits. Does not include chiropractic visits. 24 visits

Cost estimator: Calculates specific costs for hundreds of procedures, based on where you’re at with your deductible, coinsurance, etc. If a selected procedure is above fair market price, the tool will provide a list of nearby facilities where it’s offered at a lower cost. Travel assistance: If you become ill or injured while traveling more than 100 miles from home, AssistAmerica® coverage is included in your plan. Receive help with medical care, coordinating prescriptions, assistance with lost luggage, and even arrange your travel back home.

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Plan ID 739705

Prescription drug coverage Visit priorityhealth.com and search Optimized or Traditional in the Approved Drug list to see coverage and pricing information. Formulary

Traditional

Tier 1

$15 copayment; after deductible

Tier 2

$50 copayment; after deductible

Tier 3

$80 copayment; after deductible

Tier 4

20% coinsurance, $150 max; after deductible

Tier 5

20% coinsurance, $300 max; after deductible

Mail Order Preventive care

Tier 1/2/3 = 2x, after deductible

Preventive care, immunizations

Covered in full; includes women's preventative health care services, well-child visits, flu shots and routine physical exams. Get the most up-to-date list of all the care that's recommended in our Preventative Health Care Guidelines when you login to your online account at PriorityHealth.com

Laboratory and X-ray Radiology

30% coinsurance after deductible

Advanced imaging (CT/ PET/MRI)

30% coinsurance after deductible

Laboratory

30% coinsurance after deductible

Emergency services Emergency room Emergency transportation/ ambulance services Hospital care

30% coinsurance after deductible 30% coinsurance after deductible

Inpatient hospital physician 30% coinsurance after deductible services 30% coinsurance after deductible; exceptions apply Surgery and/or facility fee Bariatric surgery

30% coinsurance after deductible; covered once per lifetime

Outpatient care Skilled nursing services and residential treatment Outpatient surgery

30% coinsurance after deductible; Up to 45 days covered per member each contract year

In-home and hospice care

30% coinsurance after deductible

30% coinsurance after deductible

Rehabilitation services and devices Physical and occupational 30% coinsurance after deductible Combined maximum 50 visits per member per contract year therapy Chiropractic care

30% coinsurance after deductible Maximum 24 visits per member per contract year

Speech therapy

30% coinsurance after deductible; Maximum 50 visits per member per contract year

Covered in full after deductible Prosthetic and orthotic support Durable medical equipment Covered in full after deductible (DME) Family planning and maternity care 50% coinsurance after deductible Family planning Routine prenatal and postpartum care

Covered in full for evaluation and management; see Preventative Health Care Guidelines for recommendations and services

Maternity delivery and nursery care

30% coinsurance after deductible

Tubal ligation

Covered in full for physicians services and outpatient facility Note: Hospital inpatient charges are subject to deductible and coinsurance when in connection with delivery or other covered inpatient surgery 30% coinsurance after deductible

Vasectomy

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Plan ID 739705

HMO PriorityHSA

Coverage period: 05.01.2023 to 04.30.2024

Empowering members to take greater control of their health care spending LEPPINK'S INC This document is intended to be an easy-to-read summary to provide a general overview of your benefits. It is not a contract or legal document. Additional limitations and exclusions may apply to covered services. This plan has a specific network of providers, so check the Provider Directory prior to receiving services. Prior authorizations for certain services may apply. A complete description of benefits is contained in the Certificate of Coverage, Schedule or Agreement as applicable. Member cost-sharing Embedded Deductible The amount you pay before we begin to pay.

$3,000 individual/$6,000 family Deductible costs don't apply towards your coinsurance maximum. Out-of-network services not covered.

Coinsurance Your share of the costs of a covered health care service.

30% coinsurance for services after deductible is met, except where noted. Out-of-network services not covered.

Coinsurance maximum The most coinsurance cost share you’ll pay for covered services in a contract year. Your coinsurance cost share counts toward your out-of -pocket limit. Out-of-pocket limit The most you’ll pay in a contract year for covered services before we begin to pay 100% of the costs. Office visits

Not applicable

$6,000 individual/$12,000 family

Primary care provider (PCP) 30% coinsurance after deductible Specialists

30% coinsurance after deductible

Urgent care

30% coinsurance after deductible

Virtual Care Services For medical and behavioral health visits

Covered in full after deductible

Allergy testing, serum and injections

30% coinsurance after deductible

30% coinsurance after deductible Retail health clinic Located in a retail center, like a supermarket or pharmacy and provides care for common illnesses and services (examples: ear aches, sore throats, flu shots) Mental and behavioral health Inpatient hospital

30% coinsurance after deductible

Outpatient office visits

30% coinsurance after deductible

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In this example, Peg would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Peg would pay is

In this example, Joe would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Joe would pay is

$60 $4,060

$1,800 $1,100 $1,100

$5,600

Mia’s Simple Fracture

$3,000 20% 20% 20%

In this example, Mia would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Mia would pay is

Total Example Cost

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$0 $1,900

$1,500 $0 $400

$2,800

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

„ The plan’s overall deductible „ Specialist co-insurance „ Hospital (facility) co-insurance „ Other co-insurance

(in-network emergency room visit and follow up care)

The plan would be responsible for the other costs of these EXAMPLE covered services.

$60 $5,620

$3,000 $60 $2,500

$12,700

Total Example Cost

$3,000 20% 20% 20%

Total Example Cost

„ The plan’s overall deductible „ Specialist co-insurance „ Hospital (facility) co-insurance „ Other co-insurance This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

$3,000 20% 20% 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

„ The plan’s overall deductible „ Specialist co-insurance „ Hospital (facility) co-insurance „ Other co-insurance

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition)

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, co-payments, and co-insurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

About these Coverage Examples:

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PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section----------------------

Language Access Services: Spanish (Español): Para obtener asistencia en español, llame al número que figura en el reverso de su tarjeta de identificación de salud prioritaria. Tagalog (Tagalog): Kung kailangan mo ng tulong sa Tagalog, tawagan ang numero sa likod ng iyong Priority Health ID card. Chinese (୰ᩥ): ዴᯝᝍ㟂せ୰ᩥᖎຓ㸪寞㋏ᡴỿඛ೺ᗣ㌟௷宨⫼㠃ⓗ䔜寄. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne'.

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.

Does 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.

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: Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or [email protected]; the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov; or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. 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 information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the number on the back of your Priority Health ID card or www.priorityhealth.com; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or the Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or [email protected]. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) at 1-877-999-6442 or [email protected].

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.) x Infertility treatment - diagnostic, counseling and x Bariatric surgery x Weight loss programs planning services for the underlying cause of x Chiropractic care  infertility

Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.) x Hearing aids x Non-emergency care when traveling outside the U.S. x Acupuncture x Long-term care x Private-duty nursing x Cosmetic surgery x Routine eye care (Adult & Child) x Dental care (Adult & Child) x Routine foot care

Excluded Services & Other Covered Services:

Not covered Not covered

Child glasses

Child dental check-up

Not covered

Child eye exam Not covered

Not covered

Not covered

Not covered

30% co-insurance/ visit

Hospice service

Not covered Not covered

30% co-insurance/ visit

Skilled nursing care

Not covered

Not covered

Not covered

Durable medical equipment No charge (DME)

30% co-insurance/ visit

30% co-insurance/ visit

Rehabilitation services

Habilitation services

30% co-insurance/ visit

Home health care

What You Will Pay Services You May Need Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most)

* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.

If your child needs dental or eye care

If you need help recovering or have other special health needs

Common Medical Events

Not covered

Not covered

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Including hospice care services; excluding rehabilitation and habilitation services. Prior Authorization required, except for hospice care. Physical and occupational therapy limited to 50 visits per contract year. Osteopathic and chiropractic manipulation limited to a combined 24 visits per contract year. Speech therapy limited to 50 visits per contract year. Cardiac and pulmonary rehabilitation limited to a combined 50 visits per contract year. Prior Authorization required for Applied Behavior Analysis (ABA). Covered services include Physical, Occupational, Speech Therapy and Applied Behavior Analysis (ABA). Multiple charges may apply during one day of service. Services limited to a combined 45 days per contract year. Prior Authorization required, except for hospice care. Including rental, purchase or repair. Prior Authorization required for equipment over $1,000 and all rentals. This benefit applies to hospice services provided in the home only. Any hospice services provided in a facility will be subject to the appropriate facility benefit. Not covered

Limitations, Exceptions & Other Important Information

Services You May Need

No charge

Routine prenatal and postnatal care 30% co-insurance/ visit 30% co-insurance/ visit

30% co-insurance/ visit

Inpatient services

Delivery professional fees Delivery facility fees

30% co-insurance/ visit

Not covered Not covered

Not covered

Not covered

Not covered

Not covered

30% co-insurance/ visit

Outpatient services

Not covered

30% co-insurance/ visit

What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most)

* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.

If you are pregnant

If you need mental health, behavioral health, or substance abuse services

Facility fee (e.g., hospital If you have a hospital room) stay Physician/surgeon fee

Common Medical Events

Except in an emergency, Prior Authorization required.

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No charge for first three mental health visits with a participating provider within 90 days of discharge from a participating hospital for mental health inpatient care. Except in an emergency, Prior Authorization required. Routine prenatal and postnatal visits are covered under your Preventive Health Care Services benefit. Appropriate office visit charge may apply to physician office services for complications of pregnancy.

Prior Authorization is required except in emergencies.

Limitations, Exceptions & Other Important Information

30% co-insurance/ visit

Emergency room services

30% co-insurance/ visit

Not covered Covered at the in-network benefit level; R&C limitations apply Covered at the in-network benefit level; R&C limitations apply Covered at the in-network benefit level when obtained outside of the Service Area; R&C limitations apply

* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.

Urgent care

30% co-insurance

30% co-insurance/ visit

Physician/surgeon fees

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Non-Participating Provider (You will pay the most)

What You Will Pay

Participating Provider (You will pay the least) $15 co-pay/ retail Generic drugs prescription (Tier 1) $30 co-pay/ mail order prescription $50 co-pay/ retail Preferred brand drugs prescription (Tier 2) $100 co-pay/ mail order prescription $80 co-pay/ retail Non-preferred brand drugs prescription (Tier 3) $160 co-pay/ mail order prescription Preferred specialty drugs 20% co-insurance/ retail (Tier 4) prescription Non-Preferred specialty 20% co-insurance/ retail drugs (Tier 5) prescription Facility fee (e.g., ambulatory 30% co-insurance/ visit surgery center)

Services You May Need

medical If you need immediate Emergency transportation medical attention

If you have outpatient surgery

More information about prescription drug coverage is available at https://www.priorityhealt h.com/prog/pharmacy/p harmacy.cgi

If you need drugs to treat your illness or condition

Common Medical Events

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Urgent Care services received from a Non-Participating Provider who is located in our Service Area are not Covered.

-----------none-----------

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Including outpatient care, observation care and ambulatory surgery center care. Prior Authorization may be required.

The maximum co-pay for preferred specialty drugs is $150 per fill. The maximum co-pay for non-preferred specialty drugs is $300 per fill.

Covers up to a 31-day supply (retail prescription); Covers up to a 90-day supply (mail order prescription, excluding Specialty Drugs) 50% co-insurance/ prescription for infertility drugs.

Limitations, Exceptions & Other Important Information