Common use of Preventive Care Clause in Contracts

Preventive Care. Children’s eye exam. For more information see below. 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 ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- pocket limit for this plan? $2,000/person or $4,000/family for In-Network Providers. $4,000/person or $8,000/family for Non-Network Providers. 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, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn't cover, and Non-Network Transplants. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇- care/?alphaprefix=AZL or call (▇▇▇) ▇▇▇-▇▇▇▇ for a list of network providers. Costs may vary by site of service and how 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. the provider bills. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 20% coinsurance 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. If you have a test Diagnostic test (x-ray, blood work) 0% coinsurance 20% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 0% coinsurance 20% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Typically Generic (Tier 1) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) For more information, refer to “National Drug List” at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/pharm acyinformation/ *See Prescription Drug section Typically Preferred Brand (Tier 2) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) Typically Non-Preferred Brand and Generic drugs (Tier 3) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 20% coinsurance --------none-------- Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need immediate medical attention Emergency room care 0% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 0% coinsurance Covered as In-Network --------none-------- Urgent care 0% coinsurance 20% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 20% coinsurance 100 days/benefit period for Inpatient rehabilitation. Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 0% coinsurance Other Outpatient 0% coinsurance Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services 0% coinsurance 20% coinsurance --------none-------- If you are pregnant Office visits No charge 20% coinsurance Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 0% coinsurance 20% coinsurance Childbirth/delivery facility services 0% coinsurance 20% coinsurance If you need help recovering or have other special health needs Home health care 0% coinsurance 20% coinsurance 200 visits/benefit period. Rehabilitation services 0% coinsurance 20% coinsurance *See Therapy Services section. Habilitation services 0% coinsurance 20% coinsurance Skilled nursing care 0% coinsurance 20% coinsurance 100 days/benefit period for skilled nursing services. Durable medical equipment 0% coinsurance 20% coinsurance *See Durable Medical Equipment Section Hospice services 0% coinsurance 20% coinsurance --------none-------- If your child needs dental or eye care Children’s eye exam No charge 20% coinsurance *See Vision Services section. Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- • Dental care (Adult) • Routine foot care unless you have been diagnosed with diabetes • Cosmetic surgery • Long-term care Children’s dental check-up Glasses for a child Weight loss programs • • •

Preventive Care. Children’s eye exam. For more information see below. 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 ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- pocket limit for this plan? $2,0004,000/person or $4,0006,850/family for In-Network Providers. $4,000/person or $8,000/family for Non-Network Providers. 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, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn't cover, and Non-Network Transplants. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇- care/?alphaprefix=AZL or call (▇▇▇) ▇▇▇-▇▇▇▇ for a list of network providers. Costs may vary by site of service and how the provider bills. 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. the provider bills. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 20% coinsurance 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. If you have a test Diagnostic test (x-ray, blood work) 0% coinsurance 20% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 0% coinsurance 20% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Typically Generic (Tier 1) No $10 copay per prescription after deductible is met retail / and $20 home delivery 20% coinsurance (retail) and Not covered (home delivery) For more information, refer to “National Drug List” at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/pharm acyinformation/ *See Prescription Drug section Typically Preferred Brand (Tier 2) No $25 copay per prescription after deductible is met retail / and $50 home delivery 20% coinsurance (retail) and Not covered (home delivery) Typically Non-Preferred Brand and Generic drugs (Tier 3) No $40 copay per prescription after deductible is met retail / and $80 home delivery 20% coinsurance (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 20% coinsurance --------none-------- Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need immediate medical attention Emergency room care 0% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 0% coinsurance Covered as In-Network --------none-------- Urgent care 0% coinsurance 20% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 20% coinsurance 100 days/benefit period for Inpatient rehabilitation. * For more information about limitations and exceptions, see the plan or policy document at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 0% coinsurance Other Outpatient 0% coinsurance Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services 0% coinsurance 20% coinsurance --------none-------- If you are pregnant Office visits No charge 20% coinsurance Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 0% coinsurance 20% coinsurance Childbirth/delivery facility services 0% coinsurance 20% coinsurance If you need help recovering or have other special health needs Home health care 0% coinsurance 20% coinsurance 200 visits/benefit period. Rehabilitation services 0% coinsurance 20% coinsurance *See Therapy Services section. Habilitation services 0% coinsurance 20% coinsurance Skilled nursing care 0% coinsurance 20% coinsurance 100 days/benefit period for skilled nursing services. Durable medical equipment 0% coinsurance 20% coinsurance *See Durable Medical Equipment Section Hospice services 0% coinsurance 20% coinsurance --------none-------- If your child needs dental or eye care Children’s eye exam No charge 20% coinsurance *See Vision Services section. Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- • Dental care (Adult) • Routine foot care unless you have been diagnosed with diabetes • Cosmetic surgery • Long-term care Children’s dental check-up Glasses for a child Weight loss programs • • •

Preventive Care. Children’s eye exam. For more information see below. 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 ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- pocket limit for this plan? $2,000/person or $4,000/family for In-Network Providers. $4,000/person or $8,000/family for Non-Network Providers. 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, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn't cover, and Non-Network Transplants. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇- care/?alphaprefix=AZL or call (▇▇▇) ▇▇▇-▇▇▇▇ for a list of network providers. Costs may vary by site of service and how 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. the provider bills. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 20% coinsurance 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. If you have a test Diagnostic test (x-ray, blood work) 0% coinsurance 20% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 0% coinsurance 20% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Typically Generic (Tier 1) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) For more information, refer to “National Drug List” at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/pharm acyinformation/ *See Prescription Drug section Typically Preferred Brand (Tier 2) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) Typically Non-Preferred Brand and Generic drugs (Tier 3) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 20% coinsurance --------none-------- Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need immediate medical attention Emergency room care 0% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 0% coinsurance Covered as In-Network --------none-------- Urgent care 0% coinsurance 20% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 20% coinsurance 100 days/benefit period for Inpatient rehabilitation. Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 0% coinsurance Other Outpatient 0% coinsurance Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services 0% coinsurance 20% coinsurance --------none-------- If you are pregnant Office visits No charge 20% coinsurance Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 0% coinsurance 20% coinsurance Childbirth/delivery facility services 0% coinsurance 20% coinsurance If you need help recovering or have other special health needs Home health care 0% coinsurance 20% coinsurance 200 visits/benefit period. Rehabilitation services 0% coinsurance 20% coinsurance *See Therapy Services section. Habilitation services 0% coinsurance 20% coinsurance Skilled nursing care 0% coinsurance 20% coinsurance 100 days/benefit period for skilled nursing services. Durable medical equipment 0% coinsurance 20% coinsurance *See Durable Medical Equipment Section Hospice services 0% coinsurance 20% coinsurance --------none-------- If your child needs dental or eye care Children’s eye exam No charge 20% coinsurance *See Vision Services section. Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- 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.) • Children’s dental check-up • Glasses for a child • Weight loss programs • Cosmetic surgery • Long-term care • Dental care (Adult) • Routine foot care unless you have been diagnosed with diabetes Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Cosmetic Acupuncture • Hearing aids 1 unit every 24 months • Private-duty nursing 15,000 dollars/benefit period in a Home Setting only • Bariatric surgery • LongInfertility treatment • Routine eye care (Adult) 1 exam/2 benefit periods (In-term Network) • Chiropractic care Children’s dental check50 visits/benefit period combined with all other therapies • Most coverage provided outside the United States. See ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ 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: Connecticut Department of Insurance, ▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇, (▇▇▇) ▇▇▇-up Glasses ▇▇▇▇, (▇▇▇) ▇▇▇-▇▇▇▇, Department of Health and Human Services, Center for a child Weight loss programs • • •Consumer Information and Insurance Oversight, ▇-▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇.▇▇▇▇▇.▇▇▇.▇▇▇, 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 ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇ or call ▇-▇▇▇-▇▇▇-▇▇▇▇.

Preventive Care. Children’s eye exam. For more information see below. 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 ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- pocket limit for this plan? $2,000/person or $4,000/family for In-Network Providers. $4,000/person or $8,000/family for Non-Network Providers. 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, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn't cover, and Non-Network Transplants. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇- care/?alphaprefix=AZL or call (▇▇▇) ▇▇▇-▇▇▇▇ for a list of network providers. Costs may vary by site of service and how the provider bills. 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. the provider bills. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 20% coinsurance 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. If you have a test Diagnostic test (x-ray, blood work) 0% coinsurance 20% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 0% coinsurance 20% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Typically Generic (Tier 1) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) For more information, refer to “National Drug List” at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/pharm acyinformation/ *See Prescription Drug section illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Typically Preferred Brand (Tier 2) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) acyinformation/ *See Prescription Drug section Typically Non-Preferred Brand and Generic drugs (Tier 3) No copay per prescription after deductible is met retail / home delivery 20% coinsurance (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 20% coinsurance --------none-------- Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need immediate medical attention Emergency room care 0% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 0% coinsurance Covered as In-Network --------none-------- Urgent care 0% coinsurance 20% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 20% coinsurance 100 days/benefit period for Inpatient rehabilitation. Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 0% coinsurance Other Outpatient 0% coinsurance Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services 0% coinsurance 20% coinsurance --------none-------- If you are pregnant Office visits No charge 20% coinsurance Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 0% coinsurance 20% coinsurance Childbirth/delivery facility services 0% coinsurance 20% coinsurance If you need help recovering or have other special health needs Home health care 0% coinsurance 20% coinsurance 200 visits/benefit period. Rehabilitation services 0% coinsurance 20% coinsurance *See Therapy Services section. Habilitation services 0% coinsurance 20% coinsurance Skilled nursing care 0% coinsurance 20% coinsurance 100 days/benefit period for skilled nursing services. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) Durable medical equipment 0% coinsurance 20% coinsurance *See Durable Medical Equipment Section Hospice services 0% coinsurance 20% coinsurance --------none-------- If your child needs dental or eye care Children’s eye exam No charge 20% coinsurance *See Vision Services section. Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- • Dental care (Adult) • Routine foot care unless you have been diagnosed with diabetes • Cosmetic surgery • Long-term care Children’s dental check-up Glasses for a child Weight loss programs • • •--------none--------

Preventive Care. Children’s eye exam. For more information see below. 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 cost-sharing and before you meet your deductible. See a list of covered preventive services at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- of‐ pocket limit for this plan? $2,0004,000/person or $4,0008,000/family for In-Network Providers. $4,000/person or $8,000/family for Non-Network Providers. 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, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn't cover, and Non-Network Transplants. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes, Century Preferred. See ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇- care/?alphaprefix=AZL ▇ or call (▇▇▇) ▇▇▇-▇▇▇▇ for a list of network providers. Costs may vary by site of service and how the provider bills. 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. the provider bills. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. CT/LG/Anthem Century Preferred PPO HSA PS CSV/5WYZ/01-25 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 20% coinsurance 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. If you have a test Diagnostic test (x-ray, blood work) 0% coinsurance 20% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 0% coinsurance 20% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Tier 1 - Typically Generic $10/prescription (Tier 1retail) No copay per and $20/prescription after deductible is met retail / (home delivery delivery) 20% coinsurance (retail) and Not covered (home delivery) For more information, refer to “National Drug List” at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/pharm acyinformation/ *See Prescription Drug section Tier 2 - Typically Preferred Brand $20/prescription (Tier 2retail) No copay per and $40/prescription after deductible is met retail / (home delivery delivery) 20% coinsurance (retail) and Not covered (home delivery) Tier 3 - Typically Non-Preferred Brand and Generic drugs $30/prescription (Tier 3retail) No copay per and $60/prescription after deductible is met retail / (home delivery delivery) 20% coinsurance (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 20% coinsurance --------none-------- * For more information about limitations and exceptions, see plan or policy document at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. If you have outpatient surgery Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need immediate medical attention Emergency room care 0% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 0% coinsurance Covered as In-Network --------none-------- Urgent care 0% coinsurance 20% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 20% coinsurance 100 days/benefit period for Inpatient rehabilitation. Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 0% coinsurance Other Outpatient 0% coinsurance Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services 0% coinsurance 20% coinsurance --------none-------- If you are pregnant Office visits No charge 20% coinsurance Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., i.e. ultrasound). Childbirth/delivery professional services 0% coinsurance 20% coinsurance Childbirth/delivery facility services 0% coinsurance 20% coinsurance If you need help recovering or have other special health needs Home health care 0% coinsurance 20% coinsurance 200 visits/benefit period. --------none-------- Rehabilitation services 0% coinsurance 20% coinsurance *See Therapy Services section. Habilitation services 0% coinsurance 20% coinsurance Skilled nursing care 0% coinsurance 20% coinsurance 100 120 days/benefit period for skilled nursing services. Durable medical equipment 0% coinsurance 20% coinsurance *See Durable Medical Equipment Section Hospice services 0% coinsurance 20% coinsurance --------none-------- If your child needs dental or eye care Children’s eye exam No charge 20% coinsurance *See Vision Services section. Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- * For more information about limitations and exceptions, see plan or policy document at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic surgery • Dental care (Adult) Check-up • Routine foot care unless you have been diagnosed with diabetes • Cosmetic surgery Dental care (Adult) • Glasses for a child • Weight loss programs • Dental care (Pediatric) • Long-term care Children’s dental checkOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture • Hearing aids 1 item(s)/ear every 2 benefit periods • Private-up Glasses for duty nursing $15,000 maximum/benefit period in a child Weight loss programs Home Setting only • Bariatric surgery • •Infertility treatment • Routine eye care (Adult) 1 exam/benefit period • Chiropractic care 50 visits/benefit period combined with all other therapies • Most coverage provided outside the United States. See ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇

Preventive Care. Children’s eye exam. For more information see below. 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 ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- pocket limit for this plan? $2,0004,000/person or $4,0006,850/family for In-Network Providers. $4,000/person or $8,000/family for Non-Network Providers. 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, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn't cover, and Non-Network Transplants. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇- care/?alphaprefix=AZL or call (▇▇▇) ▇▇▇-▇▇▇▇ for a list of network providers. Costs may vary by site of service and how the provider bills. 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. the provider bills. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 20% coinsurance 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. If you have a test Diagnostic test (x-ray, blood work) 0% coinsurance 20% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 0% coinsurance 20% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Typically Generic (Tier 1) No $10 copay per prescription after deductible is met retail / and $20 home delivery 20% coinsurance (retail) and Not covered (home delivery) For more information, refer to “National Drug List” at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/pharm acyinformation/ *See Prescription Drug section * For more information about limitations and exceptions, see the plan or policy document at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Typically Preferred Brand (Tier 2) No $25 copay per prescription after deductible is met retail / and $50 home delivery 20% coinsurance (retail) and Not covered (home delivery) acyinformation/ *See Prescription Drug section Typically Non-Preferred Brand and Generic drugs (Tier 3) No $40 copay per prescription after deductible is met retail / and $80 home delivery 20% coinsurance (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 20% coinsurance --------none-------- Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need immediate medical attention Emergency room care 0% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 0% coinsurance Covered as In-Network --------none-------- Urgent care 0% coinsurance 20% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 20% coinsurance 100 days/benefit period for Inpatient rehabilitation. Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 0% coinsurance Other Outpatient 0% coinsurance Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services 0% coinsurance 20% coinsurance --------none-------- If you are pregnant Office visits No charge 20% coinsurance Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 0% coinsurance 20% coinsurance Childbirth/delivery facility services 0% coinsurance 20% coinsurance If you need help recovering or have other special health needs Home health care 0% coinsurance 20% coinsurance 200 visits/benefit period. Rehabilitation services 0% coinsurance 20% coinsurance *See Therapy Services section. Habilitation services 0% coinsurance 20% coinsurance Skilled nursing care 0% coinsurance 20% coinsurance 100 days/benefit period for skilled nursing services. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) Durable medical equipment 0% coinsurance 20% coinsurance *See Durable Medical Equipment Section Hospice services 0% coinsurance 20% coinsurance --------none-------- If your child needs dental or eye care Children’s eye exam No charge 20% coinsurance *See Vision Services section. Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- • Dental care (Adult) • Routine foot care unless you have been diagnosed with diabetes • Cosmetic surgery • Long-term care Children’s dental check-up Glasses for a child Weight loss programs • • •--------none--------

Preventive Care. Children’s eye exam. For more information see below. 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 ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of- pocket limit for this plan? $2,0004,000/person or $4,0006,850/family for In-Network Providers. $4,000/person or $8,000/family for Non-Network Providers. 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, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn't cover, and Non-Network Transplants. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇- care/?alphaprefix=AZL or call (▇▇▇) ▇▇▇-▇▇▇▇ for a list of network providers. Costs may vary by site of service and how the provider bills. 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. the provider bills. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit 0% coinsurance 20% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 20% coinsurance 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. If you have a test Diagnostic test (x-ray, blood work) 0% coinsurance 20% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 0% coinsurance 20% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at ▇▇▇▇://▇▇▇.▇▇▇▇▇ ▇.▇▇▇/▇▇▇▇▇▇▇▇▇ nformation/ Typically Generic (Tier 1) No $10 copay per prescription after deductible is met retail / and $20 home delivery 20% coinsurance (retail) and Not covered (home delivery) For more information, refer to “National Drug List” at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/pharm acyinformation/ *See Prescription Drug section Typically Preferred Brand (Tier 2) No $25 copay per prescription after deductible is met retail / and $50 home delivery 20% coinsurance (retail) and Not covered (home delivery) Typically Non-Preferred Brand and Generic drugs (Tier 3) No $40 copay per prescription after deductible is met retail / and $80 home delivery 20% coinsurance (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 20% coinsurance --------none-------- Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need immediate medical attention Emergency room care 0% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 0% coinsurance Covered as In-Network --------none-------- Urgent care 0% coinsurance 20% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 20% coinsurance 100 days/benefit period for Inpatient rehabilitation. * For more information about limitations and exceptions, see the plan or policy document at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) Physician/surgeon fees 0% coinsurance 20% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 0% coinsurance Other Outpatient 0% coinsurance Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services 0% coinsurance 20% coinsurance --------none-------- If you are pregnant Office visits No charge 20% coinsurance Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 0% coinsurance 20% coinsurance Childbirth/delivery facility services 0% coinsurance 20% coinsurance If you need help recovering or have other special health needs Home health care 0% coinsurance 20% coinsurance 200 visits/benefit period. Rehabilitation services 0% coinsurance 20% coinsurance *See Therapy Services section. Habilitation services 0% coinsurance 20% coinsurance Skilled nursing care 0% coinsurance 20% coinsurance 100 days/benefit period for skilled nursing services. Durable medical equipment 0% coinsurance 20% coinsurance *See Durable Medical Equipment Section Hospice services 0% coinsurance 20% coinsurance --------none-------- If your child needs dental or eye care Children’s eye exam No charge 20% coinsurance *See Vision Services section. Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- 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.) • Children’s dental check-up • Glasses for a child • Weight loss programs • Cosmetic surgery • Long-term care • Dental care (Adult) • Routine foot care unless you have been diagnosed with diabetes Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Cosmetic Acupuncture • Hearing aids 1 unit every 24 months • Bariatric surgery • LongInfertility treatment • Chiropractic care 50 visits/benefit period combined with all other therapies * For more information about limitations and exceptions, see the plan or policy document at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. • Private-term duty nursing 15,000 dollars/benefit period in a Home Setting only • Routine eye care Children’s dental check(Adult) 1 exam/2 benefit periods (In-up Glasses Network) • Most coverage provided outside the United States. See ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ 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 a child Weight loss programs • • •those agencies is: Connecticut Department of Insurance, ▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇, (▇▇▇) ▇▇▇-▇▇▇▇, (▇▇▇) ▇▇▇-▇▇▇▇, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, ▇-▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇.▇▇▇▇▇.▇▇▇.▇▇▇, 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 ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇ or call ▇-▇▇▇-▇▇▇-▇▇▇▇.