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Summary of Benefits and Coverage What this Plan Covers What You Pay for Covered Services The Harvard Pilgrim Best Buy HMO Coverage Period 10 01 2023 09 30 2024 Coverage for Individual Family Plan Type HMO The 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 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 www harvardpilgrim org LGsampleEOC 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 www healthcare gov sbc glossary or call 1 888 333 4742 to request a copy Important Questions What is the overall deductible Answers 1 000 member 2 000 family Benefits are administered on a Plan Year basis Are there services covered Yes emergency room care prescription drugs outpatient before you meet your mental health services preventive care provider office deductible visits routine eye exams are covered before you meet your deductibles Are there other deductibles No for specific services What is the out of pocket 7 350 member 14 700 family limit for this plan Why This Matters Generally you must pay all the costs up to the deductible amount before this plan begins to pay If you have other family members on the policy they have to meet their own individual deductible until the overall family deductible amount has been met 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 preventive services without cost sharing and before you meet your deductible See a list of covered preventive services at https www healthcare gov coverage preventive care benefits 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 you have other family members in this plan they have to meet their own out of pocket limit until the overall family out of pocket limit has been met MD0000020629_G2 RX0000015987_B2 Page 1 of 7

Important Questions Answers What is not included in the Premiums balance billing charges and health care this out of pocket limit plan doesn t cover Will you pay less if you use Yes See https www harvardpilgrim org public find a network provider a provider or call 1 888 333 4742 for a list of network providers Do you need a referral to Yes see a specialist Why This Matters Even though you pay these expenses they don t count toward the out of pocket limit This plan uses a provider network You will pay less if you use a provider in the plan s network You will pay the most if you use an out of network provider and you might receive a bill 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 for some services such as lab work Check with your provider before you get services This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist All copayment and coinsurance costs shown in this chart are after your deductible has been met if a deductible applies Common Medical Event If you visit a health care provider s office or clinic Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care screening immunization What You Will Pay Network Provider You will pay the least Out of Network Provider You will pay the most Level 1 25 copay visit deductible does not apply Level 1 25 copay visit deductible does not apply Level 2 40 copay visit deductible does not apply Not covered Not covered No charge deductible does Not covered not apply Limitations Exceptions Other Important Information None None You may have to pay for services that aren t preventive Ask your provider if the services needed are preventive Then check what your plan will pay for Page 2 of 7

Common Medical Event Services You May Need If you have a test Diagnostic test x ray blood work Imaging CT PET scans MRIs If you need drugs to treat Generic drugs your illness or condition More information about prescription drug coverage is available at www harvardpilgrim org 2023Premium4T Preferred brand drugs Non preferred brand drugs Specialty drugs If you have outpatient surgery Facility fee e g ambulatory surgery center Physician surgeon fees What You Will Pay Network Provider You will pay the least Out of Network Provider You will pay the most X rays 35 copay visit Not covered Laboratory 35 copay visit 75 copay procedure Not covered 30 Day Retail Tier 1 5 copay prescription deductible does not apply 90 Day Mail Tier 1 10 copay prescription deductible does not apply 30 Day Retail Tier 2 25 copay prescription deductible does not apply 90 Day Mail Tier 2 50 copay prescription deductible does not apply Not covered 30 Day Retail Tier 3 50 copay prescription deductible does not apply 90 Day Mail Tier 3 100 copay prescription deductible does not apply Not covered 30 Day Retail Tier 4 100 copay prescription deductible does not apply 90 Day Mail Tier 4 300 copay prescription deductible does not apply Not covered All drugs are covered in Retail Not covered Pharmacy and Mail Order Pharmacy Tiers 1 4 No charge Not covered No charge Not covered Limitations Exceptions Other Important Information None Cost sharing may vary for certain imaging services You pay retail price for Out of Network pharmacy drugs and are reimbursed minus applicable cost sharing Covered only outside of service area Some drugs must be obtained through a Specialty Pharmacy None Page 3 of 7

Common Medical Event Services You May Need If you need immediate medical attention Emergency room care Emergency medical transportation Urgent care If you have a hospital stay If you need mental health behavioral health or substance abuse services If you are pregnant Facility fee e g hospital room Physician surgeon fee Outpatient services Inpatient services Office visits Childbirth delivery professional services Childbirth delivery facility services If you need help recovering Home health care or have other special health Rehabilitation services needs Habilitation services Skilled nursing care Durable medical equipment What You Will Pay Network Provider You will pay the least Out of Network Provider You will pay the most 250 copay visit deductible does not apply No charge Limitations Exceptions Other Important Information None None Urgent care center 40 copay visit deductible does not apply No charge Urgent care center Not covered Not covered Services with non participating providers are only covered outside of the service area Cost sharing may vary based on Urgent Care location None No charge Not covered 25 copay visit deductible Not covered does not apply No charge Not covered 25 copay visit deductible Not covered does not apply No charge Not covered None Cost sharing does not apply for preventive services No charge Not covered No charge Physical Therapy 40 copay visit Occupational Therapy 40 copay visit Speech Therapy 40 copay visit No charge 20 coinsurance Not covered Not covered Not covered Not covered None Occupational physical therapy 60 combined visits Plan Year 100 days Plan Year Wigs 350 Plan Year Page 4 of 7

Common Medical Event Services You May Need Hospice services If your child needs dental or eye care Children s eye exam Children s glasses Children s dental check up Up to age of 13 What You Will Pay Network Provider You will pay the least Out of Network Provider You will pay the most No charge Not covered 25 copay visit deductible Not covered does not apply Not covered Not covered 25 copay visit deductible Not covered does not apply Limitations Exceptions Other Important Information For inpatient see If you have a hospital stay 1 exam Plan Year None 2 exams Plan Year Excluded Services Other Covered Services Services Your Plan Does NOT Cover This isn t a complete list Check your policy or plan document for other excluded services Children s glasses Cosmetic Surgery Dental Care Adult Long Term Care Non emergency care when traveling outside the U S Routine foot care except for diabetes or systemic circulatory diseases Services that are not Medically Necessary Weight Loss Programs Private duty nursing Other Covered Services This isn t a complete list Check your policy or plan document for other covered services and your costs for these services Acupuncture 20 visits Plan Year Chiropractic Care 20 visits Plan Year Infertility Treatment Bariatric surgery Hearing Aids 2 000 aid every 36 months for Routine eye care Adult 1 exam Plan Year each impaired ear up to age 22 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 the Department of Labor Employee Benefits Security Administration at 1 866 444 EBSA 3272 or www dol gov ebsa healthreform or the Department of Health and Human Services Centers for Consumer Information and Insurance Oversight at 1 877 267 2323 x61565 or www cciio cms gov or for more information on your rights to continue coverage you can contact the Member Service number listed on your ID card or call 1 888 333 4742 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 on how 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 Page 5 of 7

HPHC Member Appeals Member Services Department Harvard Pilgrim Health Care Inc 1 Wellness Way Canton MA 02021 1166 Telephone 1 888 333 4742 Fax 1 617 509 3085 Department of Labor s Employee Benefits Security Administration 1 866 444 3272 www dol gov ebsa healthreform Health Care for All 30 Winter Street Suite 1004 Boston MA 02108 1 800 272 4232 http www hcfama org helpline Massachusetts Division of Insurance 1000 Washington Street Suite 810 Boston MA 02118 6200 1 617 521 7794 Does this plan meet the Minimum Value Standard 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 Language Access Services Para obtener asistencia en Espa ol llame al 1 888 333 4742 1 888 333 4742 De assist ncia em Portugu s por favor ligue 1 888 333 4742 To see examples of how this plan might cover costs for a sample medical situation see the next section Page 6 of 7

About these Coverage Examples 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 deductible copayment and coinsurance and excluded services under the 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 Peg is Having a Baby 9 months of in network pre natal care and a hospital delivery The plan s overall deductible 1 000 Specialist copayment 40 Hospital facility 0 Other copayment 35 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 Total Example Cost 12 700 In this example Peg would pay Cost Sharing Deductibles 1 000 Copayments 200 Coinsurance 0 What isn t covered Limits or exclusions 0 The total Peg would pay is 1 200 Managing Joe s type 2 Diabetes a year of routine in network care of a well controlled condition The plan s overall deductible 1 000 Specialist copayment 40 Hospital facility 0 Other copayment 35 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 Total Example Cost 5 600 In this example Joe would pay Cost Sharing Deductibles 100 Copayments 1 600 Coinsurance 0 What isn t covered Limits or exclusions 0 The total Joe would pay is 1 700 Mia s Simple Fracture in network emergency room visit and follow up care The plan s overall deductible 1 000 Specialist copayment 40 Hospital facility 0 Other copayment 35 This EXAMPLE event includes services like Emergency room care including medical supplies Diagnostic test x ray Durable medical equipment crutches Rehabilitation services physical therapy Total Example Cost 2 800 In this example Mia would pay Cost Sharing Deductibles 1 000 Copayments 400 Coinsurance 40 What isn t covered Limits or exclusions 0 The total Mia would pay is 1 440 The plan would be responsible for the other costs of these EXAMPLE covered services Page 7 of 7