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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 01/01/2020 – 12/31/2020Coverage for: Individual Family Plan Type: HMOGold 80 HMOThe 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 /la-care-covered or call 1-855-270-2327 (TTY 711). 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 healthcare.gov/sbc-glossary or call 1-855270-2327 (TTY 711) to request a copy.Important QuestionsWhat is the overalldeductible?Are there servicescovered before you meetyour deductible?Are there otherdeductibles for specificservices?AnswersWhy This Matters: 0See the Common Medical Events chart below for your costs for the services this plan coversNoYou will have to meet the deductible before the plan pays for any servicesNoYou don’t have to meet deductibles for specific servicesWhat is the out-of-pocketlimit for this plan? 7,800 person / 15,600 familyPer calendar yearThe out-of-pocket limit is the most you could pay in a year for covered services. If you have otherfamily members in this plan, they have to meet their own out-of-pocket limits until the overallfamily out-of-pocket limit has been met.What is not included inthe out-of-pocket limit?Premiums and health care thisplan doesn’t cover.Even though you pay these expenses, they don’t count toward the out-of-pocket limits.Will you pay less if youuse a network provider?Yes. See lacare.lacare.org or call1-855-270-2327 (TTY 711) for alist of participating providers.This plan uses a provider network. You will pay less if you use a participating provider in theplan’s network. You will pay the most if you use an non-participating provider, and you mightreceive a bill from a provider for the difference between the provider’s charge and what your planpays (balance billing). Be aware, your participating provider might use a non-participating providerfor some services (such as lab work). Check with your provider before you get services.Do you need a referral tosee a specialist?Yes. Your Primary Care Physician(PCP) has to refer you.This plan will pay some or all of the costs to see a specialist for covered services but only if youhave a referral before you see the specialist.Questions: Call 1-855-270-2327 (TTY 711) or visit us at lacare.org1 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 01/01/2020 – 12/31/2020Coverage for: Individual Family Plan Type: HMOGold 80 HMOAll copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventIf you visit a healthcare provider’s officeor clinicIf you have a testServices You May NeedPrimary care visit to treat aninjury or illnessSpecialist visitPreventive care/screening/immunizationDiagnostic test (x-ray,ultrasound, laboratory work)Imaging (CT/PET scans, MRIs)If you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available atwww.lacare.orgIf you have outpatientsurgeryIf you need immediatemedical attentionTier 1 (Most Generics)Tier 2 (Preferred Brand)What You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most) 30Not covered 65Not coveredNo chargeNot covered 40 for laboratory tests 75 for x-rays,diagnostic imaging andultrasounds 275Retail - 15Mail service - 30Retail - 55Mail service - 110Limitations, Exceptions, & Other ImportantInformationNoneNoneYou may have to pay for services that aren’tpreventive. Ask your provider if the servicesyou need are preventive. Then check whatyour plan will pay for.Not coveredNoneNot coveredPrior authorization is requiredUp to 30-day supply for Retail PharmacyUp to 90-day supply for Mail Service PharmacyUp to 30-day supply for Retail PharmacyUp to 90-day supply for Mail Service PharmacyUp to 30-day supply for Retail PharmacyUp to 90-day supply for Mail Service PharmacyPrior Authorization is requiredPrior Authorization is required. Not availablethrough Mail Service.Not coveredNot coveredTier 3 (Non-Preferred Brand)Retail - 80Mail service - 160Not coveredTier 4 (Specialty drugs)20% up to 250 perscriptNot covered 300Not coveredPrior Authorization is required. 40 350Not covered 350NoneCo-pay waived if admitted 250 250NoneFacility fee (e.g., ambulatorysurgery center)Physician/surgeon feesEmergency room careEmergency medicaltransportationQuestions: Call 1-855-270-2327 (TTY 711) or visit us at lacare.org2 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 01/01/2020 – 12/31/2020Coverage for: Individual Family Plan Type: HMOGold 80 HMOCommonMedical EventIf you have a hospitalstayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesIf you are pregnantIf you need helprecovering or haveother special healthneedsWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Limitations, Exceptions, & Other ImportantInformationUrgent care 30Not coveredNoneFacility fee (e.g., hospital room) 600 per day up to 5daysNot coveredPrior Authorization is requiredPhysician/surgeon feesNo chargeNot coveredNoneOutpatient services 30Not coveredOther Outpatient items andservices 30Not coveredInpatient services 600 per day up to 5daysNot coveredPrior Authorization requiredNo chargeNot coveredNone 600 per day up to 5daysNot coveredNoneNo chargeNot coveredNoneServices You May NeedPrenatal care andpreconception visitsChild birth/delivery hospitalinpatient servicesChild birth/delivery inpatientprofessional servicesPrior Authorization is Required forPsychological Testing and Substance UseDisorder Medical TreatmentPrior Authorization is Required.Services outside if an office setting, such as atreatment center or home, that involve daily orweekly treatment delivered over several hours.Refer to plan documents for list of includedservicesHome health care 30Not coveredUp to a maximum of 100 visits per calendaryear per member by home health care agencyproviders.Prior Authorization is required.Outpatient Rehabilitationservices 30Not coveredPrior Authorization is requiredQuestions: Call 1-855-270-2327 (TTY 711) or visit us at lacare.org3 of 6

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 01/01/2020 – 12/31/2020Coverage for: Individual Family Plan Type: HMOGold 80 HMOCommonMedical EventServices You May NeedOutpatient Habilitation servicesIf your child needsdental or eye careWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most) 30Not coveredSkilled nursing care 300 per day up to 5daysNot coveredDurable medical equipmentHospice servicesChildren’s eye exam20%No chargeNo chargeNot coveredNot coveredNot coveredChildren’s glassesNo chargeNot coveredChildren’s dental check-upNo chargeNot coveredLimitations, Exceptions, & Other ImportantInformationPrior Authorization is requiredUp to a maximum of 100 days perCalendar Year per Member. PriorAuthorization is Required.Prior Authorization is requiredPrior Authorization is required1 visit per calendar year1 pair of glasses per year (or contact lenses inlieu of glasses).Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Chiropractic care Infertility treatment Private duty nursing Cosmetic surgery Long-term care Routine eye care (Adult) Dental care (Adult) Non-emergency care when traveling outside the Routine foot careU.S. Hearing aids Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture Bariatric surgery Services related to AbortionQuestions: Call 1-855-270-2327 (TTY 711) or visit us at lacare.org4 of 6