SummaryofBenefitsand Coverage:Whatthis PlanCoversWhatYouPayForCoveredServicesCoveragePeriod:03/01/2018 – 06/30/2018

HESESchoolHealthInsurance:Plan3–Wellness - $750 PlanCoveragefor:Single or Family|PlanType:PPO

The SummaryofBenefitsand Coverage(SBC)documentwill help you choosea healthplan. The SBCshows you how you and the plan wouldsharethecost forcoveredhealthcare services. NOTE:Informationaboutthecost ofthisplan (called thepremium)will be providedseparately.

This is only a summary.Formore information about your coverage, or to get a copy of the complete terms of coverage, call 800-540-2583.Forgeneral definitions of common terms, such as allowedamount,balancebilling, coinsurance, copayment, deductible, provider,or other underlined terms see the Glossary.Youcan view the Glossary at MedMutual.com/SBCor call 800-540-2583to request a copy.

ImportantQuestions / Answers / WhyThisMatters:
Whatis theoverall deductible? / $750/single,$1,500/family Network
$750/single,$1,500/family Non-Network / Generally, you must pay all of the costs from providersup to the deductibleamount before this planbegins to pay. If you have other family members on the plan, each family member must meet their ownindividual deductibleuntil the total amount of deductibleexpenses paid by all family members meets the overall family deductible.
Arethereservices covered beforeyou meet your deductible? / Yes.Certainpreventivecareandall serviceswithcopaymentsare coveredandpaidbytheplanbefore youmeetyourdeductible. / This plancovers some items and services even if you haven’t yet met the deductibleamount. Buta copaymentor coinsurancemay apply. Forexample, this plancovers certain preventiveserviceswithout cost-sharingand before you meet your deductible. Seea list of covered preventiveservices at
Arethereotherdeductibles forspecific services? / Yes, Notapplicable / Youmust pay all of the costs for these services up to the specific deductibleamount before this plan
begins to pay for these services..
Whatis theout-of-pocketlimit forthisplan? / $750/single,$1,500/family Network
$2,250/single,$4,500/family
Non-Network / The out-of-pocketlimitis 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-pocketlimitsuntil the overall family out-of-pocketlimithas been met.
Whatis notincludedin the out-of-pocketlimit? / Deductibles,premiums,
balance-billedchargesand health care this plandoesn't cover.
Certain specialty pharmacy drugs are considered non-essential health benefits and fall outside the out-of-pocket limits / Even though you pay these expenses, they don't count towardthe out-of-pocketlimit.
The costs of these drugs (though reimbursed by the manufacturer at no cost to you) will not be applied towards satisfying your out-of-pocket maximums.

SummaryofBenefitsand Coverage:Whatthis PlanCoversWhatYouPayForCoveredServicesCoveragePeriod: 03/01/2018 – 06/30/2018

HESESchoolHealthInsurance:Plan3Coveragefor:Single or Family|PlanType:PPO

The SummaryofBenefitsand Coverage(SBC)documentwill help you choosea healthplan. The SBCshows you how you and the plan wouldsharethecost forcoveredhealthcare services. NOTE:Informationaboutthecost ofthisplan (called thepremium)will be providedseparately.

This is only a summary.Formore information about your coverage, or to get a copy of the complete terms of coverage, call 800-540-2583.Forgeneral definitions of common terms, such as allowedamount,balancebilling, coinsurance, copayment, deductible, provider,or other underlined terms see the Glossary.Youcan view the Glossary at MedMutual.com/SBCor call 800-540-2583to request a copy.

ImportantQuestions / Answers / WhyThisMatters:
Will you pay less ifyou use a networkprovider? / Yes,SeeMedMutual.com/SBCorcall
800-540-2583 fora list of participating providers. / This planuses a providernetwork. Youwill pay less if you use a providerin the plan'snetwork. Youwill pay the most if you use an out-of-networkprovider,and you might receive a bill from a providerfor the difference between the provider'scharge and whatyour planpays (balancebilling).Beawareyour networkprovidermight use an out-of-networkproviderfor some services (such as lab work).Check with your providerbefore you get services.
Doyou need areferraltosee a specialist? / No / Youcan see the specialistyou choose without a referral.
All coinsurancecosts shown in this chart are after your deductiblehas been met, if a deductibleapplies. Serviceswith copaymentsare covered before you meet your deductible, unless otherwise specified.
CommonMedicalEventServices YouMay NeedWhatYouWillPayLimitations,Exceptions,Other
ImportantInformation a NetworkProvider a Non-NetworkProvider
(Youwill pay theleast)(Youwill pay themost)
Ifyouvisita healthcare provider'sofficeorclinic / Primarycarevisit to treatan injuryor illness / $25 copay/visit / $25 copay/visit, 30%
coinsurance / None
Specialist visit / $40 copay/visit / $40 copay/visit, 30%
coinsurance / None
Preventivecare/screening/
Immunization / Nocharge / $25 copay/visit, 30%
coinsurance / Youmay have to pay forservices that aren'tpreventive.Askyour providerif the servicesyou need are preventive.Thencheck whatyour plan willpay for.
Ifyouhavea test / Diagnostic test (x-ray) / 10% coinsurance / 30% coinsurance / None
Diagnostic test (bloodwork) / 10% coinsurance / 30% coinsurance / None
Imaging (CT/PETscans, MRIs) / 10% coinsurance / 30% coinsurance / None
Ifyouneeddrugstotreatyour illnessorcondition
More information is available at Express Scripts.com / Generic Copay – Retail
Generic Copay - Mail Order
Preferred Copay – Retail
Preferred Copay - Mail Order
Non-Preferred Copay – Retail
Non-Preferred Copay - Mail Order / $7.50
$15
$25
$50
$50
$100 / Does Not Apply
Does Not Apply
Does Not Apply
Does Not Apply
Does Not Apply
Does Not Apply / Covers up to a 30-day supply
Covers up to a 90-day supply
Covers up to a 30-day supply
Covers up to a 90-day supply
Covers up to a 30-day supply
Covers up to a 90-day supply
Ifyouhaveoutpatientsurgery / Facilityfee (e.g.,ambulatorysurgery center) / 10% coinsurance / 30% coinsurance / None
Physician/surgeonfees (Outpatient) / 10% coinsurance / 30% coinsurance / None
Ifyouneedimmediatemedical attention / Emergencyroomcare / $100 copay / None
Emergencymedical transportation / 10% coinsurance / 30% coinsurance / None
Urgentcare / $40 copay/visit / $40 copay/visit, 30%
coinsurance / None
Ifyouhavea hospitalstay / Facilityfee (e.g.,hospital room) / 10% coinsurance / 30% coinsurance / None
Physician/surgeonfee (inpatient) / 10% coinsurance / 30% coinsurance / None
CommonMedicalEventServices YouMay NeedWhatYouWillPayLimitations,Exceptions,Other
ImportantInformation a NetworkProvider a Non-NetworkProvider
(Youwill pay theleast)(Youwill pay themost)
Ifyouneedmentalhealth, behavioralhealth,or substanceabuseservices / Outpatient services / Benefitspaid based on correspondingmedical benefits / None
Inpatient services / Benefitspaid based on correspondingmedical benefits / None
Ifyouarepregnant / Office visits / Nocharge / 30% coinsurance / Costsharingdoes not apply to certainpreventiveservices. Dependingon the type of services, copay, coinsuranceordeductible may apply. Maternitycaremay include tests and servicesdescribed elsewherein the SBC(i.e. ultrasound).
Childbirth/deliveryprofessional services / 10% coinsurance / 30% coinsurance / None
Childbirth/deliveryfacility services / 10% coinsurance / 30% coinsurance / None
Ifyouneedhelprecoveringor haveotherspecialhealth needs / Home health care / 10% coinsurance / 30% coinsurance / None
Rehabilitation services (Physical
Therapy) / 10% coinsurance / 30% coinsurance / (40visits perbenefit period, combined withOccupational Therapy)
Habilitation services (Occupational
Therapy) / 10% coinsurance / 30% coinsurance / (40visits perbenefit period, combined withPhysicalTherapy)
Habilitation services (Speech
Therapy) / 10% coinsurance / 30% coinsurance / (20visits perbenefit period)
Skillednursingcare / 10% coinsurance / 30% coinsurance / None
Durablemedical equipment / 10% coinsurance / 30% coinsurance / None
Hospice services / 10% coinsurance / 30% coinsurance / None
Ifyourchildneedsdentalor eye care / Children'seye exam / Nocharge / $25 copay/visit, 30%
coinsurance / None
Children'sglasses / NotCovered / ExcludedService
Children'sdental check-up / NotCovered / ExcludedService

ExcludedServices &OtherCoveredServices:

Services YourPlanGenerallyDoesNOTCover(Checkyourpolicy orplan documentformoreinformationand a list ofany other excludedservices.)

•Acupuncture

•Children'sdental check-up

•Children'sglasses

•CosmeticSurgery

•DentalCare(Adult)

•HearingAids

•InfertilityTreatment

•Long-TermCare

•Non-emergencycarewhentravelingoutside the U.S.

•RoutineEyeCare(Adult)

•RoutineFootCare

•WeightLoss Programs

OtherCoveredServices (Limitationsmay apply tothese services. This isn'ta completelist. Please see yourplan document.)

•BariatricSurgery•ChiropracticCare•Private-DutyNursing

YourRightstoContinueCoverage:There are agencies that can help if you wantto continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services,Centerfor Consumer Information and Insurance Oversight, at 877-267-2323x61565 orcciio.cms.gov. Other coverage options may be available to you, including buying individual insurance coverage through the Health InsuranceMarketplace. Formore information about theMarketplace, visit HealthCare.govor call

800-318-2596.

YourGrievanceand AppealsRights: There are agencies that can help if you have a complaint against yourplan for a denial of a claim. This complaint is called a grievance or appeal. Formore information about your rights, look at the explanation of benefits you will receive for that medicalclaim. Yourplan documents also provide complete information to submit aclaim, appeal, or a grievance for any reason to yourplan. Formore information about your rights, this notice, or assistance, contact yourplan at

800-540-2583.

Doesthis plan provideMinimum EssentialCoverage?Yes.

If you don't have Minimum Essential Coveragefor a month, you'll have to make a payment whenyou file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Doesthis plan meet Minimum ValueStandards?Yes.

If your plan doesn't meet the Minimum Value Standards, you may be eligible for apremium tax creditto help you pay for a plan through the Marketplace.

------Tosee examples ofhow this plan might cover costsforsample medical situations,see the next section------The coverage example numbers assume that the patient does not use an HRAor FSA.If you participate in an HRAor FSAand use it to pay for out-of-pocketexpenses, then your costs may be lower.

Aboutthese CoverageExamples:

This is nota cost estimator.Treatmentsshown are just examples of howthisplan might cover medical care. Youractual costs will be different depending on the actual care you receive, the prices yourproviderscharge, and many other factors. Focus on thecost sharing amounts (deductibles,copayments and coinsurance)and excluded services under the plan. Use this information to compare the portion of costs you might pay under different healthplans. Please
note these coverage examples are based on self-only coverage.
Pegis havinga baby
(9 months of in-networkpre-natalcare and a hospital delivery) / ManagingJoe’s type 2 Diabetes (a year of routine in-networkcare of a well-controlledcondition) / Mia’s SimpleFracture
(in-networkemergency room visit and follow up care)
  • The plan'soverall deductible
/ $750 /
  • The plan'soverall deductible
/ $750 /
  • The plan'soverall deductible
/ $750
  • Specialistcopay
/ $40 /
  • Specialistcopay
/ $40 /
  • Specialistcopay
/ $40
  • Hospital(facility)coinsurance
/ 10% /
  • Hospital(facility)coinsurance
/ 10% /
  • Hospital(facility)coinsurance
/ 10%
  • Other coinsurance
/ 10% /
  • Other coinsurance
/ 10% /
  • Other coinsurance
/ 10%

This EXAMPLEevent includesservices like: Specialist office visits (prenatalcare) Childbirth/DeliveryProfessionalServices Childbirth/DeliveryFacility Services

Diagnostic tests (ultrasoundsand blood work)

Specialist visit (anesthesia)

This EXAMPLEevent includesservices like:

Primarycare physician office visits (includingdisease education)

Diagnostic tests (bloodwork)

Prescriptiondrugs

Durable medical equipment(glucosemeter)

This EXAMPLEevent includesservices like: Emergencyroom care(includingmedical supplies) Diagnostic test (x-ray)

Durable medical equipment(crutches)

Rehabilitation services (physicaltherapy)

TotalExample Cost$12,800TotalExample Cost$7,400TotalExample Cost$1,900

In this example, Pegwouldpay:In this example, Joe wouldpay:In this example, Mia wouldpay:

Cost Sharing
Deductibles* / $750
Copayments / $0
Coinsurance / $800
What isn’tcovered
Limits or exclusions / $100
The totalPegwouldpay is / $1,650

Note:These numbers assume the patient does not participate in theplan's wellness program.If you participate in theplan's wellness program, you may be able to reduce your costs. Formore information about the wellness program, please contact: 800-540-2583.

*Note:This plan has other deductibles for specific services included in this coverage example. See"Arethere otherdeductibles for specific services?”rowabove.

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