Thisisonlyasummary.If youwant moredetail aboutyourcoverage andcosts,youcangetthe completetermsin thepolicy orplan documentatwww.choices.mus.edu orbycalling1-877-501-1722.

ImportantQuestions / Answers / WhythisMatters:
Whatistheoverall deductible? / $500/person In-Network / In-network -- You must pay most costs up to deductible amount before this plan starts to pay unless otherwise stated, such as services with a copayment, and deductible does not apply to preventive services
Arethereother deductiblesforspecific services? / $750person Out-of-Network / Out-of-network – a separate deductible
Isthereanout–of– pocket limitonmy expenses? / $3500/person In-Network
$6000/person Out-of-Network / In-network – maximum out-of-pocket amount - includes deductible, coinsurance and copayments
Out-of-network – a separateout-of-pocket maximum - includes deductible,
coinsurance, copayments
Whatisnotincludedin theout–of–pocket limit? / non-covered services, balance billing / Even though you pay these expenses they are not included in the out-of-pocket limit
Isthereanoverall annuallimitonwhat theplan pays? / No / There may be day limits or visit limits on some services, but no overall dollar limit
Doesthisplan usea networkofproviders? / Yes / See or call 1-877-590-1596 to find a network provider
DoI needareferralto seeaspecialist? / No / The coinsurance is higher if you choose an out-of-network specialist
Arethereservicesthis plan doesn’t cover? / Yes / See “exclusions” in Summary Plan Description (SPD)

OMBControlNumbers1545-2229,

1210-0147,and0938-1146

•Co-paymentsarefixed dollaramounts(forexample,$15) youpayforcoveredhealthcare,usuallywhenyoureceivetheservice.

•Co-insuranceis yourshareofthecostsofacoveredservice,calculatedas apercentoftheallowedamountfortheservice.Forexample,if theplan’s allowedamountfor an overnighthospitalstay is $1,000,yourco-insurancepaymentof25% wouldbe$250. Thismaychangeif youhaven’tmetyourdeductible.

•Theamounttheplan paysforcoveredservicesis based on theallowedamount.Ifan out-of-networkprovidercharges morethanthe allowedamount,youmayhavetopay thedifference.Forexample,ifan out-of-networkhospitalcharges$1,500foran overnight stayand theallowedamountis $1,000,youmay havetopaythe$500difference.(Thisis calledbalancebilling.)

•Thisplan may encourageyoutouse in-network providersbychargingyoulowerdeductibles,copaymentsand/or coinsurance

amounts.

Common
MedicalEvent / ServicesYouMayNeed / Yourcostifyouuse an / LimitationsExceptions
In-network
Provider / Out-of-network
Provider
Ifyouvisitahealth careprovider’soffice or clinic / Primary carevisit totreatan injury orillness / $15 copayment / 35%
Specialistvisit / $15 copayment / 35%
Otherpractitioner - acupuncture/naturopath
Chiropractic office visit/manipulation / Up to $25 a visit
$15 copayment / Up to $25 a visit
35% / You pay all cost over$25/max 15visits
Max 20 visits
Preventivecare/screening/immunization / 0%, no deductible / 35%
Ifyou haveatest / Diagnostictest(x-ray,bloodwork) / 25% / 35%
Imaging(CT/PET scans,MRIs) / 25% / 35% / May require prior authorization
Ifyou needdrugsto treatyourillnessor condition
More information aboutprescription drug coverageis availableat / URx / Retail (30 days) / Mailorder (90 days)
Generic Drugs TIER A / $0 copay / $0 copay
PreferredBrand Drugs TIER B / $15 copay / $30 copay
TIER C
TIER D
TIER F
Specialty drugs S
(see URx in Choices) / $40 copay
50% of discount price
100% of discount price
$50 or $200 copay at
Diplomat Pharmacy / $80 copay
Ifyou have outpatientsurgery / Facility fee(e.g.,ambulatorysurgerycenter) / 25% / 35%
Physician/surgeonfees / 25% / 35%
Ifyou need / Emergencyroomservices / $125 copayment / $125 copayment / Room chg only/then ded & coinsurance cocoinsuranceurance
Common
MedicalEvent / ServicesYouMayNeed / Yourcostifyouuse an / LimitationsExceptions
In-network
Provider / Out-of-network
Provider
immediatemedical attention / Emergencymedicaltransportation / $200 copayment / $200 copayment
Urgent care / $50 copayment / $50 copayment
Ifyou havea hospitalstay / Facility fee(e.g.,hospitalroom) / 25% / 25%
Physician/surgeonfee / 25% / 35%
Ifyou have mental health,behavioral health,orsubstance abuseneeds / Mental/Behavioralhealthoutpatientservices / 1st 4 at 0, then $15 / 35%
Mental/Behavioralhealthinpatientservices / 25% / 35%
Substance use disorderoutpatientservices / 1st 4 at 0, then $15 / 35%
Substance use disorderinpatientservices / 25% / 35%
Ifyouarepregnant / Prenatalandpostnatalcare / $15 copayment / 35%
Deliveryandall inpatientservices / 25% / 35%
Ifyou needhelp recoveringorhave otherspecialhealth needs / Homehealthcare / $15 copayment / 35% / Needs prior auth/maximum 30 days/yr
Rehabilitationservices inpatient / 25% / 35% / 30 days/yr
Rehabilitationservices outpatient / $15 copayment / 35%
5 / 30 visits/yr
Skillednursingcare / 25% / 35% / 30 days/yr – needs prior authorization
Durablemedicalequipment / 25% / 35%
Hospice service / 25% / 25% / Maximum is 6 months
Ifyouneeddentaloreyecare / Eyeexam **covered through Health Plan
Glasses **optional through BCBSMT
g / 0% one per year / 35% one per year / See Choices book for allowances
Dentalcheck-up **optional Delta Dental / Fee schedule payment

Excluded Services and OtherCoveredServices:

ServicesYourPlanDoesNOTCover(This isn’ta completelist. Checkyourpolicyorplan documentfor otherexcludedservices.)

• work related accident or illness• Cosmetic procedures• Invitro fertilization

OtherCoveredServices(This isn’ta completelist. Checkyourpolicyorplan documentforother coveredservicesandyourcostsforthese services.)

• organ transplant * preventive services * medically necessary travel with prior authorization, $1500 max/yr

YourRightstoContinueCoverage:

You can keep this coverage as long as premiums are paid, unless your employment terminates or work hours drop below 20 hours. You may elect to

keep the coverage by electing COBRA after employment terminates if you have no other coverage. Please see your Human Resources office for

directions regarding election of COBRA benefits.

GrievanceandAppealsRights:

If youhaveacomplaint oraredissatisfiedwithadenialof coverageforclaimsunderyourplan,youmaybeable toappealorfile agrievance. For questionsaboutyourrights,thisnotice,orassistance,youcancontact:PacificSource at 1-877-590-1596, or MUS EB at 1-877-501-1722.

––––––––––––––––––––––Toseeexamplesofhowthisplan mightcovercostsforasamplemedical situation,seethenextpage.––––––––––––––––––––––

About theseCoverage

Examples:

Theseexamplesshowhowthisplanmight cover medicalcarein givensituations. Usethese examplestosee,in general,howmuchfinancial protectionasamplepatientmightgetiftheyare

covered underdifferentplans.

Havingababy

(normaldelivery)

Amount owedtoproviders:$7,540

Planpays$5140 + presc drugs

Patient pays$2200+ presc copays

Sample care costs: $7540

Managingtype2diabetes

(routinemaintenanceof

awell-controlledcondition)

Amount owedtoproviders:$4,100

Planpays$1745 + presc drugs

Patient pays$855 + presc copays

Sample care costs:$4100

Thisis

notacost estimator.

Don’tusetheseexamplesto estimateyouractualcosts underthisplan.Theactual careyoureceive willbe different fromthese examples,andthe costof thatcarewill alsobe different.

See thenextpagefor importantinformationabout theseexamples.

Patient pays:

Patient pays:

QuestionsandanswersabouttheCoverageExamples:

Whataresomeof the assumptionsbehindthe CoverageExamples?

•Costsdon’tincludepremiums.

•Samplecarecostsarebasedon national averagessuppliedbytheU.S. DepartmentofHealthandHuman Services,andaren’tspecifictoa particulargeographic area orhealthplan.

•Thepatient’sconditionwasnot an excludedorpreexistingcondition.

•All servicesand treatments startedand endedin thesamecoverageperiod.

•Thereareno othermedicalexpensesfor any membercoveredunder thisplan.

•Out-of-pocketexpensesarebased only on treatingtheconditionintheexample.

•Thepatientreceivedall carefromin- networkproviders.Ifthepatienthad receivedcarefromout-of-network providers,costs wouldhavebeenhigher.

WhatdoesaCoverageExample show?

Foreachtreatmentsituation,theCoverage Examplehelpsyou seehowdeductibles,co- payments,andco-insurancecanaddup.It alsohelpsyou see whatexpensesmightbeleft uptoyoutopaybecausetheserviceor treatment isn’tcoveredorpaymentis limited.

DoestheCoverageExample predictmyowncareneeds?

No.Treatmentsshown arejust examples.

Thecareyou wouldreceiveforthis conditioncouldbedifferentbasedonyour doctor’s advice,yourage,howseriousyour conditionis,andmanyotherfactors.

DoestheCoverageExample predictmyfutureexpenses?

No.CoverageExamples arenotcost estimators.Youcan’t use theexamplesto estimatecostsforanactualcondition. They areforcomparativepurposesonly.Your owncosts willbedifferentdependingon

thecareyoureceive, thepricesyour

providerscharge,andthereimbursement

yourhealthplanallows.

CanIuseCoverageExamples to compareplans?

Yes.Whenyoulook attheSummaryof BenefitsandCoverage for otherplans, you’llfindthesameCoverageExamples. Whenyoucompareplans,checkthe “Patient Pays”box in eachexample.The smaller thatnumber,themore coverage theplan provides.

Arethereother costsIshould considerwhencomparing plans?

Yes.An importantcost is thepremium youpay.Generally,theloweryour premium,themoreyou’llpayin out-of- pocket costs, suchas co-payments, deductibles,andco-insurance.You shouldalsoconsidercontributionsto accountssuchas healthsavingsaccounts (HSAs), flexible spendingarrangements (FSAs)orhealthreimbursementaccounts (HRAs)thathelpyoupayout-of-pocket expenses.