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:THE ROCK CHURCH AND THE ROCK ACADEMY : AetnaOpen Access Managed Choice Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2017 - 12/31/2017Coverage for: Individual Family Plan Type: POSThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan documentat https://www.aetna.com/sbcsearch/getpolicydocs?u 071400-070020-001647 or by calling 1-888-982-3862.Important QuestionsAnswersNetwork: Individual 500 / Family 1,000.Out–of–Network: Individual 500 / Family 1,000. Does not apply to office visits,prescription drugs, emergency care, andpreventive care in-network.Are there other deductiblesNo.for specific services?Why this Matters:You must pay all the costs up to the deductible amount before this plan beginsto pay for covered services you use. Check your policy or plan document to seewhen the deductible starts over (usually, but not always, January 1st). See thechart starting on page 2 for how much you pay for covered services after youmeet the deductible.You don't have to meet deductibles for specific services, but see the chartstarting on page 2 for other costs for services this plan covers.Is there anout-of-pocket limiton my expenses?The out-of-pocket limit is the most you could pay during a coverage period(usually one year) for your share of the cost of covered services. This limithelps you plan for health care expenses.What is the overalldeductible?What is not included inthe out-of-pocket limit?Is there an overallannual limit on whatthe plan pays?Yes. Network: Individual 2,500 / Family 5,000. Out–of–Network: Individual 5,000 /Family 10,000.Premiums, balance-billed charges, penaltiesfor failure to obtain pre-authorization forservice, and health care this plan does notcover.Even though you pay these expenses, they don't count toward the out-ofpocket limit.No.The chart starting on page 2 describes any limits on what the plan will pay forspecific covered services, such as office visits.Does this plan use anetwork of providers?Yes. See www.aetna.com or call1-888-982-3862 for a list of networkproviders.If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctor orhospital may use an out-of-network provider for some services. Plans use theterm in-network, preferred, or participating for providers in their network. Seethe chart starting on page 2 for how this plan pays different kinds of providers.Do I need a referral tosee a specialist?No.You can see the specialist you choose without permission from this plan.Are there services thisplan doesn't cover?Yes.Some of the services this plan doesn't cover are listed on page 5. See yourpolicy or plan document for additional information about excluded services.Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined termsused in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request acopy.071400-070020-0016471 of 8

:THE ROCK CHURCH AND THE ROCK ACADEMY : AetnaOpen Access Managed Choice Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2017 - 12/31/2017Coverage for: Individual Family Plan Type: POSCopayments are fixed dollar amounts (for example, 15) you pay for covered health care, usually when you receive the service.Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if theplan's allowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change if youhaven't met your deductible.The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay and the allowedamount is 1,000, you may have to pay the 500 difference. (This is called balance billing.)This plan may encourage you to use network providers by charging you lower deductibles, copayments, and coinsurance amounts.CommonMedical EventServices You May NeedPrimary care visit to treat an injury orillnessIf you visit a healthSpecialist visitcare provider's officeor clinicOther practitioner office visitIf you have a testPreventive care/ screening/immunizationDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs)Your Cost IfYou Use aNetwork ProviderYour Cost IfYou Use anOut–of–NetworkProvider 25 copay/visit40% coinsurance 30 copay/visit40% coinsurance40% coinsurance,except Chiropracticcare not covered 30 copay/visitNo charge40% coinsurance20% coinsurance30% coinsurance40% coinsurance50% coinsuranceLimitations & ExceptionsIncludes Internist, General Physician,Family Practitioner, Pediatrician,Gynecologist or –––––––––––Coverage is limited to 12 visits per calendaryear for in-network Chiropractic care.Age and frequency schedules may tions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined termsused in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request acopy.071400-070020-0016472 of 8

:THE ROCK CHURCH AND THE ROCK ACADEMY : AetnaOpen Access Managed Choice Summary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventServices You May NeedIf you need drugs totreat your illness orconditionGeneric drugsMore informationabout prescriptiondrug coverage isavailable iliesPremier Four TierOpen FormularyPreferred brand drugsNon-preferred brand drugsSpecialty drugsIf you haveoutpatient surgeryFacility fee (e.g., ambulatory surgerycenter)Physician/surgeon feesIf you needimmediate medicalattentionEmergency room servicesEmergency medical transportationUrgent careIf you have a hospital Facility fee (e.g., hospital room)stayPhysician/surgeon feeIf you have mentalMental/Behavioral health outpatientserviceshealth, behavioralhealth, or substance Mental/Behavioral health inpatientabuse needsservicesYour Cost IfYou Use aNetwork ProviderCopay/prescription: 15 (retail), 30 (mailorder)Copay/prescription: 25 (retail), 50 (mailorder)Copay/prescription: 40 (retail), 80 (mailorder)Coverage Period: 01/01/2017 - 12/31/2017Coverage for: Individual Family Plan Type: POSYour Cost IfYou Use anOut–of–NetworkProvider50% coinsurance aftercopay/prescription: 15 (retail)50% coinsurance aftercopay/prescription: 25 (retail)50% coinsurance aftercopay/prescription: 40 (retail)20% copay up to a 150 maximum/prescriptionNot covered20% coinsurance40% coinsurance20% coinsurance20% coinsurance after 100 copay/visit,deductible waived20% coinsurance 35 copay/visit20% coinsurance after 150 copay/stay20% coinsurance40% coinsurance20% coinsurance after 100 copay/visit,deductible waived20% coinsurance 35 copay/visit40% coinsurance after 300 copay/stay40% coinsurance 30 copay/visit40% coinsurance20% coinsurance after 150 copay/stay40% coinsurance after 300 copay/stayLimitations & ExceptionsCovers 30 day supply (retail), 31-90 daysupply (mail order). Includes contraceptivedrugs & devices obtainable from apharmacy, oral fertility drugs. No charge forformulary generic FDA-approved women'scontraceptives in-network. Review yourformulary for prescriptions requiringprecertification or step therapy forcoverage. Your cost will be higher forchoosing Brand over Generics.First prescription must be filled at aparticipating retail pharmacy or AetnaSpecialty Pharmacy Networks. Subsequentfills must be through Aetna SpecialtyPharmacy o coverage for non-emergency use.No coverage for non-emergency transport.No coverage for non-urgent use.Pre-authorization required forout-of-network uthorization required forout-of-network care.Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined termsused in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request acopy.071400-070020-0016473 of 8

:THE ROCK CHURCH AND THE ROCK ACADEMY : AetnaOpen Access Managed Choice Summary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventIf you are pregnantIf you need helprecovering or haveother special healthneedsServices You May NeedCoverage for: Individual Family Plan Type: POSYour Cost IfYou Use anOut–of–NetworkProviderSubstance use disorder outpatientservicesSubstance use disorder inpatientservicesPrenatal and postnatal care 30 copay/visit40% coinsurance20% coinsurance after 150 copay/stayNo charge40% coinsurance after 300 copay/stay40% coinsuranceDelivery and all inpatient services20% coinsurance after 150 copay/stay40% coinsurance after 300 copay/stayHome health care20% coinsurance40% coinsuranceRehabilitation servicesHabilitation services 25 copay/visit 25 copay/visit40% coinsurance40% coinsuranceSkilled nursing care20% coinsurance40% coinsuranceDurable medical equipment50% coinsurance20% coinsurance after 150 copay/stay forinpatient; 30copay/visit foroutpatient50% coinsurance40% coinsurance after 300 copay/stay forinpatient; 40%coinsurance foroutpatientEye examNo charge40% coinsuranceGlassesDental check-upNot coveredNot coveredNot coveredNot coveredHospice serviceIf your child needsdental or eye careYour Cost IfYou Use aNetwork ProviderCoverage Period: 01/01/2017 - 12/31/2017Limitations & ––––––––––Pre-authorization required forout-of-network ––––––––Includes outpatient postnatal care.Pre-authorization may be required forout-of-network care.Coverage is limited to 120 visits percalendar year. Pre-authorization required forout-of-network ––––––––Coverage is limited to treatment of Autism.Coverage is limited to 60 days per calendaryear. Pre-authorization required forout-of-network ––––––––Pre-authorization required forout-of-network care.Coverage is limited to 1 routine eye examper 24 months.Not covered.Not covered.Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined termsused in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request acopy.071400-070020-0016474 of 8

:THE ROCK CHURCH AND THE ROCK ACADEMY : AetnaOpen Access Managed Choice Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2017 - 12/31/2017Coverage for: Individual Family Plan Type: POSExcluded 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.)AcupunctureBariatric surgeryCosmetic surgeryDental care (Adult & Child)Glasses (Child)Hearing aidsLong-term careNon-emergency care when traveling outside theU.S.Private-duty nursingRoutine foot careWeight loss programs - Except for requiredpreventive services.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.)Chiropractic care - Coverage is limited to 12 visitsper calendar year for in-network only.Infertility treatment - Coverage is limited to thediagnosis and treatment of underlying medicalcondition.Routine eye care (Adult) - Coverage is limited to 1routine eye exam per 24 months.Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay whilecovered under the plan. Other limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at 1-888-982-3862. You may also contact your state insurance department, the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and HumanServices at 1-877-267-2323 x61565 or www.cciio.cms.gov.Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. If your group health plan is subject toERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform. You may also contact the California Department of Insurance, Consumer Communications Bureau Health Unit, 300 SouthSpring Street, South Tower, Los Angeles, CA 90013, 1-800-927-HELP (4357), 1-800-482-4833 TDD, http://www.insurance.ca.govAdditionally, a consumer assistance program can help you file your appeal. Contact the California Department of Insurance at the contact information providedaboveQuestions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined termsused in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request acopy.071400-070020-0016475 of 8

:THE ROCK CHURCH AND THE ROCK ACADEMY : AetnaOpen Access Managed Choice Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2017 - 12/31/2017Coverage for: Individual Family Plan Type: POSDoes this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provideminimum essential coverage.Does this Coverage Meet Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This healthcoverage does meet the minimum value standard for the benefits it provides.Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined termsused in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request acopy.071400-070020-0016476 of 8

:THE ROCK CHURCH AND THE ROCK ACADEMY : AetnaOpen Access Managed Choice Coverage ExamplesAbout these CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.This is nota costestimator.Don't use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care also will bedifferent.See the next page forimportant information aboutthese examples.Coverage Period: 01/01/2017 - 12/31/2017Coverage for: Individual Family Plan Type: POSHaving a babyManaging type 2 diabetes(normal delivery)(routine maintenance ofa well-controlled condition)Amount owed to providers: 7,540Plan pays: 5,740Patient pays: 1,800Sample care costs:Hospital charges (mother)Routine obstetric careHospital charges (baby)AnesthesiaLaboratory testsPrescriptionsRadiologyVaccines, other preventiveTotal 2,700 2,100 900 900 500 200 200 40 7,540Patient pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotal 500 200 900 200 1,800Amount owed to providers: 5,400Plan pays: 3,520Patient pays: 1,880Sample care costs:PrescriptionsMedical Equipment and SuppliesOffice Visits and ProceduresEducationLaboratory testsVaccines, other preventiveTotal 2,900 1,300 700 300 100 100 5,400Patient pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotalQuestions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined termsused in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request acopy. 500 800 500 80 1,880071400-070020-0016477 of 8

:THE ROCK CHURCH AND THE ROCK ACADEMY : AetnaOpen Access Managed Choice Coverage ExamplesCoverage Period: 01/01/2017 - 12/31/2017Coverage for: Individual Family Plan Type: POSQuestions and answers about the Coverage Examples:What are some of the assumptionsbehind the Coverage Examples?Costs don't include premiums.Sample care costs are based on nationalaverages supplied by the U.S. Departmentof Health and Human Services, and aren'tspecific to a particular geographic area orhealth plan.The patient's condition was not anexcluded or preexisting condition.All services and treatments started andended in the same coverage period.There are no other medical expenses forany member covered under this plan.Out-of-pocket expenses are based only ontreating the condition in the example.The patient received all care fromin-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.What does a CoverageExample show?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn't covered or payment is limited.Does the Coverage Examplepredict my own care needs?No. Treatments shown are just examples.The care you would receive for thiscondition could be different, based on yourdoctor's advice, your age, how serious yourcondition is, and many other factors.Does the Coverage Examplepredict my future expenses?No. Coverage Examples are not costestimators. You can't use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Yourown costs will be different depending onthe care you receive, the prices yourproviders charge, and the reimbursementyour health plan allows.Can I use Coverage Examples tocompare plans?Yes. When you look at the Summary ofBenefits and Coverage for other plans,you'll find the same Coverage Examples.When you compare plans, check the "PatientPays" box in each example. The smaller thatnumber, the more coverage the planprovides.Are there other costs I shouldconsider when comparing plans?Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, the more you'll pay inout-of-pocket costs, such as copayments,deductibles, and coinsurance. You shouldalso consider contributions to accounts suchas health savings accounts (HSAs), flexiblespending arrangements (FSAs) or healthreimbursement accounts (HRAs) that helpyou pay out-of-pocket expenses.Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined termsused in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request acopy.071400-070020-0016478 of 8

Assistive TechnologyPersons using assistive technology may not be able to fully access the following information. For assistance, please call 1-888-982-3862.Smartphone or TabletTo view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store.Non-DiscriminationAetna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Aetna does notexclude people or treat them differently because of race, color, national origin, age, disability, or sex.Aetna:Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languagesIf you need these services, contact our Civil Rights Coordinator.If you believe that Aetna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can filea grievance with: Civil Rights Coordinator, PO Box 14462, Lexington, KY 40512, 1-800-648-7817, TTY 711, Fax 859-425-3379, [email protected] HMO/HNO Members: Civil Rights Coordinator, PO Box 24030 Fresno CA, 93779, 1-800-648-7817, TTY 711, Fax 860-262-7705, [email protected] can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civilrights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal,available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).Complaint forms are available at a is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry HealthCare plans and their affiliates.

TTY: 711Language Assistance:For language assistance in your language call 1-888-982-3862 at no cost.Albanian -Për asistencë në gjuhën shqipe telefononi falas në 1-888-982-3862.Amharic -ለቋንቋ እገዛ በ አማርኛ በ 1-888-982-3862 በነጻ ይደውሉArabic -1-888-982-3862Armenian -Լեզվի ցուցաբերած աջակցության (հայերեն) զանգի 1-888-982-3862 առանց գնով:Bahasa Indonesia -Untuk bantuan dalam bahasa Indonesia, silakan hubungi 1-888-982-3862 tanpa dikenakan biaya.Bantu-Kirundi -Niba urondera uwugufasha mu Kirundi, twakure kuri iyi nomero 1-888-982-3862 ku busaBengali-Bangala -বাংলায় ভাষা সহায়তার জন্য বিনামুল্যে 1-888-982-3862-তে কল করুন।Bisayan-Visayan -Alang sa pag-abag sa pinulongan sa (Binisayang Sinugboanon) tawag sa 1-888-982-3862 nga walay bayad.Burmese ုဘဲ င့္ ရန္ 1-888-982-3862 ကို ေခၚဆိုပါ။Catalan -Per rebre assistència en (català), truqui al número gratuït 1-888-982-3862.Chamorro -Para ayuda gi fino' (Chamoru), ågang 1-888-982-3862 sin gåstu.Cherokee -ᎾᏍᎩᎾ ᎦᏬᏂᎯᏍᏗ ᏗᏂᏍᏕᎵᏍᎩ ᎾᎿᎢ (ᏣᎳᎩ) ᏫᏏᎳᏛᎥᎦ 1-888-982-3862 ᎤᎾᎢ Ꮭ ᎪᎱᏍᏗ ᏧᎬᏩᎵᏗ ᏂᎨᏒᎾ.Chinese -欲取得繁體中文語言協助,請撥打 1-888-982-3862,無需付費。Choctaw -(Chahta) anumpa ya apela a chi I paya hinla 1-888-982-3862.Cushite -Gargaarsa afaan Oromiffa hiikuu argachuuf lakkokkofsa bilbilaa 1-888-982-3862 irratti bilisaan bilbilaa.Dutch -Bel voor tolk- en vertaaldiensten in het Nederlands gratis naar 1-888-982-3862.French -Pour une assistance linguistique en français appeler le 1-888-982-3862 sans frais.French Creole -Pou jwenn asistans nan lang Kreyòl Ayisyen, rele nimewo 1-888-982-3862 gratis.German -Benötigen Sie Hilfe oder Informationen in deutscher Sprache? Rufen Sie uns kostenlos unter der Nummer 1-888-982-3862 an.Greek -Για γλωσσική βοήθεια στα Ελληνικά καλέστε το 1-888-982-3862 χωρίς χρέωση.Gujarati -ગુજરાતીમાં ભાષામાં સહાય માટે કોઈ પણ ખર્ચ વગર 1-888-982-3862 પર કૉલ કરો.

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THE ROCK CHURCH AND THE ROCK ACADEMY : Aetna: Open Access Managed Choice Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthRe