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Message Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Gravie Comfort $6,000 OOPM (AETNA)Coverage Period:Coverage for: Individual, Spouse and FamilyPlan Type: PPOThe 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 acopy of the complete terms of coverage, visit www.gravie.com/. For definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlinedterms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 855.451.8365 to request a copy.Important Questions Answers Why This Matters:Whatis the overall deductible?In-network providers: $6,000 individual/$12,000 family.Out-of-network providers: $10,000 individual/$20,000 family.See the Common Medical Events chart below for a summary of coverage provided by thisplan. For some services,a copayment or payment toward the out-of-pocket may apply.Arethere services covered before youmeet your deductible?Yes. In-network preventive care services, office visits (primary and specialty care), on-line care through Gravie's telemedicine service provider, labs and related imaging work, urgent care visits and generic prescriptions are covered at no cost. The no cost portion only applies to labs/imaging related to the office visit.Thisplan covers some items and services even if you haven't met the deductible amount. For example, this plancovers certain preventive services withoutcost-sharing. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Copay/coinsurance may apply to some services.Arethere other deductibles for specificservices?No.You don’t have to meetdeductibles for specific services.Whatis the out-of-pocket limit for thisplan?In-network providers: $6,000 individual / $12,000 family ($6,000 per family member). Out-of-networkproviders: Not applicable. For ease of reference, your out-of-pocket maximum will be referred to as OOPM through this document.Theout-of-pocket limit is the most you could pay in a year for covered services. If you have other family membersin this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limithasbeen met. The in-network OOPM is the same as the deductible. There is no out-of-pocket limit for out-of-network providers.Whatis not included in the out-of-pocketlimit?Premiums, balance-billing charges, and health care this plan doesn’t cover.Eventhough you pay these expenses, they don’t count toward the out-of-pocket limit.Willyou pay less if you use anetwork provider?Yes. See www.aetna.com/asa or call 855.451.8365 for a list of network providers.Thisplan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the mostif 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 yourplan pays (balance billing). Be aware your network provider might use anout-of-network provider for some services (such as lab work). Check with your provider before you get services.Doyou need a referral to see aspecialist?No.You can see thespecialist you choose without a referral.1 of 5Gravie Comfort $6000 OOPM AETNA

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayLimitations, Exceptions, & Other Important InformationCommon Medical Event Services You May NeedIn-Network Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Ifyou visit a health care provider’soffice or clinicPrimarycare visit to treat aninjury or illnessNo charge50% coinsurance after deductibleAccessto lower-cost online care services may be available through Gravie'stelemedicineservice provider. Dialysis, chemotherapy, radiation and certaininjectabledrugs are not free when administered at an office or clinic. For moreinformation,you can contact Gravie Customer Service at 855.451.8365.SpecialistvisitNo charge50% coinsurance after deductibleAccessto lower-cost online care services may be available through Gravie'stelemedicineservice provider. Dialysis, chemotherapy, radiation and certaininjectabledrugs are not free when administered at an office or clinic.Preventivecare/screening/immunizationNo charge50% coinsurance after deductibleSomeover-the-counter (OTC) drugs can be obtained with a prescription at the preventive level of coverage.Ifyou have a testDiagnostictest (x-ray, bloodwork)Office/Clinic: No charge. Hospital: No charge after OOPM50% coinsurance after deductibleNocharge services limited to tests done within office or clinic. OOPM applies to tests associated with ahospitalization. Prior authorization may berequired.Imaging(CT/PET scans, MRIs)Office/Clinic: No charge. Hospital: No charge after OOPM50% coinsurance after deductibleNocharge services limited to tests done within office or clinic. OOPM applies to tests associated with ahospitalization. Prior authorization may berequired.Ifyou need drugs to treat yourillness or condition Moreinformation about prescriptiondrug coverageis available at 855.451.8365GenericdrugsRetail: No charge. Mail: No charge.Not coveredRetail and mail order available up to 90-day supply.Preferredbrand drugsRetail,30-day supply: $75 copay Retail,90-day supply: $150copayMail,90-day supply: $150 copayNot coveredRetail and mail order available up to 90-day supply.Non-preferred branddrugsRetail and mail: No charge after OOPMNot coveredRetail and mail order available up to 90-day supply.SpecialtydrugsNot coveredRetail and mail order available up to 30-day supply.Ifyou have outpatient surgeryFacilityfee (e.g., ambulatorysurgery center)No charge after OOPM50% coinsurance after deductiblePrior authorization may be required for certain outpatient surgery procedures.Physician/surgeonfeesNo charge after OOPM50% coinsurance after deductiblePrior authorization may be required.Ifyou need immediate medicalattentionEmergencyroom services$250 copay$250 copayServices in connection with an Emergency are covered at in-network level.EmergencymedicaltransportationNo charge after OOPMNo charge after OOPMServices in connection with an Emergency are covered at in-network level.UrgentcareNo charge50% coinsurance after deductibleNone2 of 5* For more information about limitations and exceptions, see the Plan or policy document at www.gravie.comApproved Retail and Mail: No cost w/PrudentRx or SmartRX

3 of 5* For more information about limitations and exceptions, see the Plan or policy document at www.gravie.comWhat You Will PayLimitations, Exceptions, & Other Important InformationCommon Medical Event Services You May NeedIn-Network Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Ifyou have a hospital stayFacilityfee (e.g., hospital room)No charge after OOPM50% coinsurance after deductiblePrior authorization may be required. Prior authorization required for all inpatient hospitalizations.Physician/surgeonfeesNo charge after OOPM50% coinsurance after deductiblePrior authorization may be required.Ifyou need mental health, behavioralhealth, or substanceabuse servicesOutpatientservicesOffice/Clinic: No charge. Hospital: No charge after OOPM50% coinsurance after deductiblePrior authorization may be required. Access to lower-cost online care services may be available through Gravie's telemedicine service providerInpatientservicesNo charge after OOPM50% coinsurance after deductiblePrior authorization may be requiredIfyou are pregnantOfficevisitsNo charge50% coinsurance after deductibleCost sharing does not apply for preventive services. Depending on the typeof services, copayment, coinsurance, deductible may apply.Childbirth/delivery professionalservicesNo charge after OOPM50% coinsurance after deductibleNoneChildbirth/deliveryfacility servicesNo charge after OOPM50% coinsurance after deductiblePrior authorization may be requiredIfyou need help recoveringor have other specialhealth needsHomehealth careNo charge after OOPM50% coinsurance after deductible100 visit limit per year.RehabilitationservicesOffice/Clinic: No charge. Hospital: No charge after OOPM50% coinsurance after deductibleDigital physical therapy services may be available at no charge. Prior authorization is recommended for other physical, occupational, and speech therapy.HabilitationservicesOffice/Clinic: No charge. Hospital: No charge after OOPM50% coinsurance after deductibleDigital physical therapy services may be available at no charge. Prior authorization is recommended for other physical, occupational, and speech therapy. Prior authorization may be required.Skillednursing careNo charge after OOPM50% coinsurance after deductible120 days per member per year. Prior authorization may be requiredDurablemedicalequipmentNo charge after OOPM50% coinsurance after deductibleLimits may apply. Prior authorization may be required.HospiceserviceNo charge after OOPM50% coinsurance after deductiblePriorauthorization may be required.Ifyour child needs dental oreye careChildren’seye examNo charge50% coinsurance after deductibleLimit of 1 routine exam per year.Children’sglassesNot coveredNot coveredNoneChildren’sdental check-upNot coveredNot coveredNoneExcluded Services & Other Covered Services:Servicesyour plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)• Bariatric surgery • Cosmetic Surgery (unless determined to be reconstructive)• Hearing aids • Long-term care• Acupuncture• Dental care (Adults)• Non-emergency care when traveling outside the U.S.• Infertility treatment• Routine foot care (except certain conditions)• Weight loss programs (except preventive obesity counseling/screening)

OtherCovered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)•Chiropractic care• Private-duty nursing (Inpatient Only)•Routine eye care (Adult)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 the agency is the Department of Labor’s Employee Benefits Security Administration at 1.866.444.EBSA (3272) /www.dol.gov/ebsa/healthreform.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.govor call 1.800.318.2596.Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your planfor a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanationof 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 yourrights, this notice, or assistance, you can contact Gravie Customer Service at 855.451.8365 or the Department of Labor’s Employee Benefits Security Administration at 1.866.444.EBSA (3272)/www.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimumEssential 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 MinimumEssential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf your plandoesn'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:To see examples of how this plan might cover costs for a sample medical situation, see the next section.4 of 5* For more information about limitations and exceptions, see the Plan or policy document at www.gravie.com

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 providerscharge, 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.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)■ The plan'soverall deductible■ Specialist copay■ Hospital (facility) coinsurance■ Other coinsuranceThis EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility ServicesDiagnostictests (ultrasounds and blood work) Specialistvisit (anesthesia)Total Example Cost $12,700In this example, Peg would pay:Cost SharingDeductibles$6,000Copayments$0Coinsurance$0What isn'tcoveredLimits or Exclusions $60Thetotal Peg would pay is $6,060Managing Joe's Type 2 Diabetes(a year of routine in-network care of a well-controlled condition)■ The plan'soverall deductible■ Specialist copay■ Hospital (facility) coinsurance■ Other coinsuranceThis EXAMPLE event includes services like:Primary care physician office visits (including disease education) Diagnostic tests(blood work)Prescription drugsDurable Medical Equipment (glucose meter)Total Example Cost $5,600In this example, Joe would pay:Cost SharingDeductibles$800Copayments$1,000Coinsurance$0What isn'tcoveredLimits or Exclusions $30Thetotal Joe would pay is $1,830Mia's Simple Fracture(in-network emergency room visit and follow up care)■ The plan'soverall deductible■ Specialist copay■ Hospital (facility) copay■ Other coinsuranceThis EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests(x-ray)Durable medical equipment(crutches) Rehabilitation services(physical therapy)Total Example Cost $2,800In this example, Mia would pay:Cost SharingDeductibles$1,200Copayments$300Coinsurance$0What isn'tcoveredLimits or Exclusions $0Thetotal Mia would pay is $1,500The plan would be responsible for the other costs of these EXAMPLE covered services.$6,000$0 0%0%5 of 5$6,000$0 0%0%$6,000$0$250 0%