Return to flip book view

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2025-12/31/2025 Group Name: Bemis Manufacturing: US PPO Coverage for: Individual / Family | Plan Type: PPO (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019) (DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 6 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) 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 share 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, https://my.centivo.com or call 1-833-716-2159. 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 www.healthcare.gov/sbc-glossary or call 1-800-318-2596 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? In-Network $850 Individual / $2,550 Family Out-of-Network $1,700 Individual / $5,100 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Preventive care and primary care services are covered before you meet your deductible. 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 https://www.healthcare.gov/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? In-Network $4,300 Individual / $8,600 Family Out-of-Network $8,600 Individual / $17,200 Family 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, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Certain specialty pharmacy drugs are considered non-essential health benefits and fall outside the out-of-pocket limits. The cost of these drugs (though reimbursed by the manufacturer at no cost to you) will not be applied towards satisfying your out-of-pocket limits. Maintenance medications not filled for 90 days at a designated network pharmacy are not covered and will not be applied towards your out-of-pocket limit. Will you pay less if you use a network provider? Yes. See https://hcpdirectory.cigna.com or call 1-833-716-2159 for a list of 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 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. Do you need a referral to see a specialist? No You can see the specialist you choose without referral.

* For more information about limitations and exceptions, see the plan or policy document at https://my.centivo.com. Page 2 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-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 $10 Copayment Deductible does not apply 45% Coinsurance Virtual visits and telephonic visits are the same as in-office visits. Specialist visit 25% Coinsurance 45% Coinsurance Virtual visits and telephonic visits are the same as in-office visits. Preventive care/screening/ immunization No charge 45% Coinsurance You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 25% Coinsurance 45% Coinsurance None Imaging (CT/PET scans, MRIs) 25% Coinsurance 45% Coinsurance Preauthorization may be required. If you don't get preauthorization, benefits may be reduced. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.Express-Scripts.com or call 1-800-451-6245. Generic (Tier 1 drugs) Retail: $10 Copayment Deductible does not apply Mail Order: $15 Copayment Deductible does not apply Retail: $10 Copayment Deductible does not apply Covers 30-day supply (retail subscription); Retail 90-day option available at 3 times the 30-day supply cost; 31–90-day supply (mail order prescription). Mandatory 90-day for maintenance drugs at designated in-network pharmacy or Home Delivery. Non-Network prescription claims must be manually submitted for reimbursement. Specialty drugs must go through Express Scripts specialty pharmacy. SaveOnSP Specialty Pharmacy Copay Assistance Program applies to specialty drugs on the SaveOnSP list. Other specialty drugs have cost sharing based on the applicable tier. Certain specialty pharmacy drugs are considered non-essential health benefits and fall outside the out-of-pocket limits. The cost of these drugs (though reimbursed by the manufacturer at no cost to you) will not be applied towards satisfying your out-of-pocket limits. Please see “Important Questions” regarding the plan’s out-of-pocket limit. Preferred Brand (Tier 2 drugs) Retail & Mail Order: 25% Coinsurance Retail: 25% Coinsurance Non-Preferred Brand (Tier 3 drugs) Retail & Mail Order: 40% Coinsurance Retail: 40% Coinsurance Specialty Drugs (Tier 4 drugs) Pharmacy and Mail Order: 25% or 40% Coinsurance, based on applicable Preferred Brand or Non-Preferred Brand tier Pharmacy: 25% or 40% Coinsurance, based on applicable Preferred Brand or Non-Preferred Brand tier

* For more information about limitations and exceptions, see the plan or policy document at https://my.centivo.com. Page 3 of 6 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 25% Coinsurance 45% Coinsurance Preauthorization may be required. If you don't get preauthorization, benefits may be reduced. Physician/surgeon fees 25% Coinsurance 45% Coinsurance None If you need immediate medical attention Emergency room care $200 Copayment, then 25% Coinsurance $200 Copayment, then 25% Coinsurance Copayment is waived if admitted. Network deductible applies. Emergency medical transportation 25% Coinsurance 25% Coinsurance Urgent care 25% Coinsurance 45% Coinsurance Network deductible and coinsurance applies if out of area. If you have a hospital stay Facility fee (e.g., hospital room) 25% Coinsurance 45% Coinsurance Preauthorization may be required. If you don't get preauthorization, benefits may be reduced. Physician/surgeon fees 25% Coinsurance 45% Coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit: $10 Copayment Deductible does not apply All Others: 25% Coinsurance 45% Coinsurance Preauthorization may be required. If you don't get preauthorization, benefits may be reduced. Inpatient services 25% Coinsurance 45% Coinsurance If you are pregnant Office visits 25% Coinsurance 45% Coinsurance Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Failure to obtain preauthorization for childbirth if inpatient stay exceeds 48 hours for normal delivery and 96 hours after a cesarean delivery may result in benefits being reduced. Childbirth/delivery professional services 25% Coinsurance 45% Coinsurance Childbirth/delivery facility services 25% Coinsurance 45% Coinsurance If you need help recovering or have other special health needs Home health care 25% Coinsurance 45% Coinsurance 40 visits/year. Preauthorization may be required. If you don't get preauthorization, benefits may be reduced. Rehabilitation services 25% Coinsurance 45% Coinsurance Preauthorization may be required. If you don't get preauthorization, benefits may be reduced. Habilitation services 25% Coinsurance 45% Coinsurance

* For more information about limitations and exceptions, see the plan or policy document at https://my.centivo.com. Page 4 of 6 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Skilled nursing care 25% Coinsurance 45% Coinsurance 90 visits/year combined with Inpatient Medical Rehabilitation. Preauthorization may be required. If you don't get preauthorization, benefits may be reduced. Durable medical equipment 25% Coinsurance 45% Coinsurance Excludes vehicle modifications, home modifications, exercise, and bathroom equipment. Hospice services 25% Coinsurance 45% Coinsurance Preauthorization may be required. If your child needs dental or eye care Children’s eye exam 25% Coinsurance 45% Coinsurance Routine eye exam limited to one per member per calendar year. Children’s glasses Not Covered Not Covered Not a covered service under this plan. Children’s dental check-up Not Covered Not Covered Coverage is limited to an oral risk assessment each year as required by PPACA. 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.)  Acupuncture  Cosmetic surgery  Infertility Treatment  Long-term care  Non-emergency care when traveling outside the U.S.  Private Duty Nursing  Routine dental care (Adult)  Routine foot care-except for specific conditions  Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Bariatric Surgery (1 surgery per lifetime)  Chiropractic Care (20 visits/year combined with Osteopath Manipulation)  Hearing Aids (1 per ear every 3 years)  Routine eye care (Adult - 1 visit/year) 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: your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or Affordable Care Act | U.S. Department of Labor (dol.gov) or the U.S. Department of Health and Human Services at 1-877-267-2323 x 61565 or www.CMS.gov. 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 on how 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:

* For more information about limitations and exceptions, see the plan or policy document at https://my.centivo.com. Page 5 of 6 Centivo at 1-833-716-2159. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA x3272 or dol.gov/ebsa/healthreform. Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet 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 [1-833-716-2159].] [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [1-833-716-2159].] [Chinese (中文): 如果需要中文的帮助，请拨打这个号码 [1-833-716-2159].] [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [1-833-716-2159].] PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 6 of 6 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 different depending 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 you might pay under different health plans. Please note these coverage examples are based on self-only coverage.  The plan’s overall deductible $850  Specialist [cost sharing] 25%  Hospital (facility) [cost sharing] 25%  Other [cost sharing] 25% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $850 Copayments $20 Coinsurance $2,900 What isn’t covered Limits or exclusions $0 The total Peg would pay is $3,770  The plan’s overall deductible $850  Specialist [cost sharing] 25%  Hospital (facility) [cost sharing] 25%  Other [cost sharing] 25% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $850 Copayments $200 Coinsurance $900 What isn’t covered Limits or exclusions $0 The total Joe would pay is $1,950  The plan’s overall deductible $850  Specialist [cost sharing] 25%  Hospital (facility) [cost sharing] 25%  Other [cost sharing] 25% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $850 Copayments $210 Coinsurance $400 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,810 The plan would be responsible for the other costs of these EXAMPLE covered services. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care)