SBC-86199PA0010003-02Underwritten by Pennsylvania Health and Wellness, Inc.

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Summary of Benefits and Coverage: What this Plan covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019Ambetter from PA Health & Wellness: Ambetter Balanced Care 3 (2019) Coverage for: Individual/Family | Plan Type: HMO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This isonly a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit

https://Ambetter.PAhealthwellness.com/2019-brochures.html, or call 1-833-510-4727 (Relay 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 athttps://www.healthcare.gov/sbc-glossary or call 1-833-510-4727 (Relay 711) to request a copy.

Important Questions Answers Why This Matters:

What is the overalldeductible?

$0. See the Common Medical Events chart below for your costs for services this plan covers.

Are there servicescovered before youmeet your deductible?

There is no deductible.There is no deductible. See a list of covered preventive services athttps://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there otherdeductibles for specificservices?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for thisplan?

Not Applicable. This plan does not have an out-of-pocket-limit on your expenses.

What is not included inthe out-of-pocket limit?

Not Applicable. This plan does not have an out-of-pocket-limit on your expenses.

Will you pay less if youuse a network provider?

Yes. See Find a Provider or call 1-833-510-4727 (Relay 711) for a listof network providers.

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 aprovider for the difference between the provider’s charge and what your plan pays (balancebilling). 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.

Do you need a referralto see a specialist?

No. You can see the specialist you choose without a referral.

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Common MedicalEvent

Services You May Need Limitation, Exceptions, & Other ImportantInformation

If you visit a healthcare provider's officeor clinic

Primary care visit to treat aninjury or illness

No charge Not covered -----None-----

Specialist visit No charge Not covered -----None-----

Preventive care/ screening/immunization

No charge Not covered

You may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what your planwill pay for.

If you have a test

Diagnostic test (x-ray, bloodwork)

No charge Not covered

Prior authorization may be required. Failure toobtain prior authorization for any service thatrequires prior authorization may result in reductionof benefits. See your policy for more details.

Imaging (CT/PET scans,MRIs)

No charge Not covered Prior authorization may be required.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will PayNetwork Provider (You

will pay the least)Out-of-Network Provider(You will pay the most)

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Common MedicalEvent

Services You May Need Limitation, Exceptions, & Other ImportantInformation

If you need drugs totreat your illness orconditionMore informationabout prescriptiondrug coverage isavailable at PreferredDrug List.

Generic drugs (Tier 1) No charge Not covered Prescription drugs are provided up to 31 daysretail and up to 90 days through mail order.

Preferred brand drugs (Tier 2) No charge Not coveredPrior authorization may be required. Prescriptiondrugs are provided for up to 31 days retail and upto 90 days through mail order.

Non-preferred brand drugs(Tier 3) No charge Not covered

Prior authorization may be required. Prescriptiondrugs are provided for up to 31 days retail and upto 90 days through mail order.

Specialty drugs (Tier 4) No charge Not coveredPrior authorization may be required. Prescriptiondrugs are provided for up to 31 days retail and upto 90 days through mail order.

If you haveoutpatient surgery

Facility fee (e.g., ambulatorysurgery center)

No charge Not covered Prior authorization may be required.

Physician/surgeon fees No charge Not covered Prior authorization may be required.

What You Will PayNetwork Provider (You

will pay the least)Out-of-Network Provider(You will pay the most)

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Common MedicalEvent

Services You May Need Limitation, Exceptions, & Other ImportantInformation

If you needimmediate medicalattention

Emergency room care No charge No charge -----None-----Emergency Medicaltransportation

No charge No charge -----None-----

Urgent Care No charge Not covered -----None-----

If you have ahospital stay

Facility fee (e.g., hospitalroom)

No charge Not covered Prior authorization may be required.

Physician/surgeon fees No charge Not covered Prior authorization may be required.If you need mentalhealth, behavioralhealth, or substanceabuse services

Outpatient services No charge Not coveredPrior authorization may be required. (PCP andother practitioner visits do not require priorauthorization)

Inpatient services No charge Not covered Prior authorization may be required.

What You Will PayNetwork Provider (You

will pay the least)Out-of-Network Provider(You will pay the most)

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Common MedicalEvent

Services You May Need Limitation, Exceptions, & Other ImportantInformation

If you are pregnant

Office visits No charge Not covered

Prior authorization not required for deliveries withinthe standard timeframe per federal regulation, butmay be required for other services. Cost-sharingdoes not apply for preventive services.Depending on the type of services, coinsurance,deductible or copayment may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).

Childbirth/deliveryprofessional services

No charge Not covered

Prior authorization not required for deliveries withinthe standard timeframe per federal regulation, butmay be required for other services. Cost-sharingdoes not apply for preventive services.Depending on the type of services, coinsurance,deductible or copayment may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery facilityservices

No charge Not covered

Prior authorization not required for deliveries withinthe standard timeframe per federal regulation, butmay be required for other services. Cost-sharingdoes not apply for preventive services.Depending on the type of services, coinsurance,deductible or copayment may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).

What You Will PayNetwork Provider (You

will pay the least)Out-of-Network Provider(You will pay the most)

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Common MedicalEvent

Services You May Need Limitation, Exceptions, & Other ImportantInformation

If you need helprecovering or haveother special healthneeds

Home health care No charge Not covered Prior authorization may be required. 60 Visits peryear.

Rehabilitation services No charge Not covered

30 Visits per year for Speech Therapy. Combinedlimit of 30 Visits per Year for PT & OT. 36 Visits peryear (includes Cardiac, Pulmonary, & RespiratoryTherapy) *These limits do not apply when providedfor a mental health/substance use disorderdiagnosis.

Habilitation services No charge Not covered

30 Visits per year for Speech Therapy. Combinedlimit of 30 Visits per Year for PT & OT. 36 Visits peryear (includes Cardiac, Pulmonary, & RespiratoryTherapy) *These limits do not apply when providedfor a mental health/substance use disorderdiagnosis.

Skilled nursing care No charge Not covered Prior authorization may be required. 120 Days peryear.

Durable medical equipment No charge Not covered Prior authorization may be required.

Hospice services No charge Not covered Prior authorization may be required. Respite care -maximum of 7 days every 6 months.

If your child needsdental or eye care

Children's eye exam No charge Not covered 1 Exam per yearChildren's glasses No charge Not covered 1 Item per year.Children's dental check-up Not covered Not covered -----None-----

Excluded Services & Other Covered Services

What You Will PayNetwork Provider (You

will pay the least)Out-of-Network Provider(You will pay the most)

Services your Plan Generally Does NOT cover (Check your policy or plan documentation for more information and a list of any other excluded services.)Abortion (Except in cases ofrape, incest, or when the life ofthe mother is endangered)Acupuncture

Bariatric surgery

Cosmetic surgery

Dental care

Hearing aids

Long-term care

Non-emergency care whentraveling outside the U.S.Private-duty nursing

Routine eye care (Adult)

Weight loss programs

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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: Ambetter from PA Health & Wellness at 1-833-510-4727 (Relay 711); Pennsylvania Insurance Department, 1209 Strawberry Square, Harrisburg, PA 17111, Phone No. (877) 881-6388. 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 www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Pennsylvania Insurance Department, 1209 Strawberry Square, Harrisburg, PA 17111, Phone No. (877) 881-6388. Additionally, a consumer assistance program can help you file your appeal. Contact 1-877-881-6388.

Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-833-510-4727 (Relay 711)Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-833-510-4727 (Relay 711)Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-833-510-4727 (Relay 711)Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-833-510-4727 (Relay 711)

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)Chiropractic care (Limited to 20specialists' visits per benefitperiod)Infertility treatment (Only coveredfor artificial insemination)

Routine foot care (For medicallynecessary treatment)

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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs youmight pay under different health plans. Please note these coverage examples are based on self-only coverage

This EXAMPLE even includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery facility ServicesDiagnostic test (ultrasounds and blood work)Specialist visit (anesthesia)

Total Example Cost $12,800

In this example, Peg would pay:Cost Sharing

Deductibles $0Copayments $0Coinsurance $0

What isn't coveredLimits or exclusions $60The total Peg would pay is $60

Peg is Having a baby

(9 months of in-network prenatal care and ahospital delivery)

The plan's overall deductibleSpecialist coinsuranceHospital (facility) coinsuranceOther coinsurance

$00%0%0%

This EXAMPLE even includes services like:Primary care physician office visits (includesdisease education)Diagnostic tests (blood work)Prescription DrugsDurable medical equipment (glucose meter)

Total Example Cost $7,400

In this example, Joe would pay:Cost Sharing

Deductibles $0Copayments $0Coinsurance $0

What isn't coveredLimits or exclusions $60The total Joe would pay is $60

Managing Joe's type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

The plan's overall deductibleSpecialist coinsuranceHospital (facility) coinsuranceOther coinsurance

$00%0%0%

This EXAMPLE even includes services like:Emergency room care (including medicalsupplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (Physical therapy)

Total Example Cost $1,900

In this example, Mia would pay:Cost Sharing

Deductibles $0Copayments $0Coinsurance $0

What isn't coveredLimits or exclusions $0The total Mia would pay is $0

Mia's Simple Fracture

(in-network emergency room visit and followup care)

The plan's overall deductibleSpecialist coinsuranceHospital (facility) coinsuranceOther coinsurance

$00%0%0%

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

© 2018 Pennsylvania Health & Wellness, Inc. All rights reserved.

Statement of Non-Discrimination

Ambetter from PA Health & Wellness complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Ambetter from PA Health & Wellness does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Ambetter from PA Health & Wellness:

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 languages

If you need these services, contact Ambetter from PA Health & Wellness at 1-833-510-4727 (Relay 711).

If you believe that Ambetter from PA Health & Wellness 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 file a grievance with: Ambetter from PA Health & Wellness, Attn: Ambetter Grievances and

Appeals Department, 12515-8 Research Blvd, Suite 400, Austin, TX 78759, 1-833-510-4727 (Relay 711), Fax, 1-833-886-7956. You can file a

grievance by mail or fax. If you need help filing a grievance, Ambetter from PA Health & Wellness is available to help you. You can also file a civil rights 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., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.