Customer Name: SISC Benefit Plan 8119 (SCR) & 8118 (NCR) HC2 TYPE HSA3; $3000DED; 20%OP; 20%IP; $30/20%SP RX

Principal Benefits for Kaiser Permanente HSA-Qualified Deductible HMO Plan (10/1/18—09/30/19) "Kaiser Permanente HSA-Qualified Deductible HMO Plan" is a health benefit plan that meets the requirements of Section 223(c)(2) of the Internal Revenue Code. For a complete explanation, please refer to the EOC. Accumulation Period The Accumulation Period for this plan is 1/1/18 through 12/31/18 (calendar year). Out-of-Pocket Maximum(s) and Deductible(s) For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below.

For Services that are subject to the Plan Deductible or the Drug Deductible, you must pay Charges for covered Services you receive during the Accumulation Period until you reach the deductible amounts listed below. All payments you make toward your deductible(s) apply to the Plan Out-of-Pocket Maximum amounts listed below.

Note: The Plan Deductible amount is subject to increase if the U.S. Department of the Treasury changes the minimum deductible required in High Deductible Health Plans.

Amounts Per Accumulation Period

Self-Only Coverage (Family of one Member)

Family Coverage Each Member in a Family of

two or more Members

Family Coverage Entire Family of two or more

Members Plan Out-of-Pocket Maximum $5,950 $5,950 $11,900 Plan Deductible $3,000 $3,000 $6,000 Drug Deductible None None None Professional Services (Plan Provider office visits) You Pay

Most Primary Care Visits and most Non-Physician Specialist Visits ......................... 20% Coinsurance after Plan Deductible Most Physician Specialist Visits ................................................................................ 20% Coinsurance after Plan Deductible Routine physical maintenance exams, including well-woman exams ....................... No charge (Plan Deductible doesn't apply) Well-child preventive exams (through age 23 months) ............................................. No charge (Plan Deductible doesn't apply) Family planning counseling and consultations .......................................................... No charge (Plan Deductible doesn't apply) Scheduled prenatal care exams ................................................................................ No charge (Plan Deductible doesn't apply) Routine eye exams with a Plan Optometrist ............................................................. 20% Coinsurance (Plan Deductible doesn't apply) Hearing exams .......................................................................................................... No charge (Plan Deductible doesn't apply) Urgent care consultations, evaluations, and treatment ............................................. 20% Coinsurance after Plan Deductible Most physical, occupational, and speech therapy ..................................................... 20% Coinsurance after Plan Deductible Outpatient Services You Pay

Outpatient surgery and certain other outpatient procedures ..................................... 20% Coinsurance after Plan Deductible Allergy injections (including allergy serum) ............................................................... 20% Coinsurance after Plan Deductible Most immunizations (including the vaccine) .............................................................. No charge (Plan Deductible doesn't apply) Most X-rays and laboratory tests............................................................................... 20% Coinsurance after Plan Deductible Preventive X-rays, screenings, and laboratory tests as described in the EOC ......... No charge (Plan Deductible doesn't apply) Covered individual health education counseling ....................................................... No charge (Plan Deductible doesn't apply) Covered health education programs ......................................................................... No charge (Plan Deductible doesn't apply) Hospitalization Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ............. 20% Coinsurance after Plan Deductible Emergency Health Coverage You Pay Emergency Department visits ................................................................................... 20% Coinsurance after Plan Deductible Ambulance Services You Pay Ambulance Services ................................................................................................. 20% Coinsurance after Plan Deductible Prescription Drug Coverage You Pay

Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy................................................................. $10 for up to a 30-day supply after Plan Deductible Most generic refills through our mail-order service ................................................ $20 for up to a 100-day supply after Plan

Deductible

25864.29.1.PDM - Hc2 Type HSA3;$3000ded;20%op;20%ip;$30/20%sp Rx (continues)

Proposed Benefit Summary (continued)

Most brand-name items at a Plan Pharmacy ......................................................... $30 for up to a 30-day supply after Plan Deductible Most brand-name refills through our mail-order service......................................... $60 for up to a 100-day supply after Plan

Deductible Most specialty items at a Plan Pharmacy .............................................................. 20% Coinsurance (not to exceed $150) for up to a

30-day supply after Plan Deductible Durable Medical Equipment (DME) You Pay DME items in accord with our DME formulary guidelines.......................................... 20% Coinsurance after Plan Deductible Mental Health Services You Pay

Inpatient psychiatric hospitalization........................................................................... 20% Coinsurance after Plan Deductible Individual outpatient mental health evaluation and treatment ................................... 20% Coinsurance after Plan Deductible Group outpatient mental health treatment ................................................................. 20% Coinsurance after Plan Deductible Chemical Dependency Services You Pay

Inpatient detoxification .............................................................................................. 20% Coinsurance after Plan Deductible Individual outpatient chemical dependency evaluation and treatment ...................... 20% Coinsurance after Plan Deductible Group outpatient chemical dependency treatment ................................................... 20% Coinsurance after Plan Deductible Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period) .................................. No charge after Plan Deductible Other You Pay

Skilled nursing facility care (up to 100 days per benefit period) ................................ 20% Coinsurance after Plan Deductible Prosthetic and orthotic devices ................................................................................. No charge after Plan Deductible Hospice care ............................................................................................................. No charge after Plan Deductible

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts . For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies).

25864.29.1.PDM - Hc2 Type HSA3;$3000ded;20%op;20%ip;$30/20%sp Rx 25864.29.1.PDM

The next time you schedule an appointment at Kaiser Permanente, you may be offered a video visit with your doctor.

• Convenient access from your home or office

• Secure and easy way to visit your doctor

• Saves travel time and expense

All you need is a computer with a high-speed internet connection and a webcam or a smartphone mobile device ( iOS iPhone or iPad or Android mobile device) using the latest version of the KP Preventive Care App.

Visit kp.org/mydoctor/videovisits for more information.

Video Visitsa picture is worth a thousand words

© 2013, TPMG, Inc. All rights reserved. Regional Health Education. 010731-015 (9/13)

Experience BETTER… with SISC’s Value-Added ServicesSISC offers much more than conventional benefits coverage. We provide access and

convenience to our membership through these innovative programs.

Advance Medical

Call 1-855-201-9925

OR

Go to advance-medical.net/sisc

MDLive

Register by calling MDLive at 1-888-632-2738

OR

Go to mdlive.com/sisc

Costco

Call 1-800-774-2678 (press 1) to find a Costco location.

Employee Assistance ProgramSISC EAP

All employees at member districts may access free resources if they need help with personal concerns—emotional, marital, financial, interpersonal addiction and recovery, legal, stress, and more. Daycare and eldercare referral services are also available. The EAP is available to all members of the employee’s household.

Counseling Services—Call EAP to schedule an in-person visit with a local provider

Confidential—Privacy is protected.

Convenient—24/7 access, holidays included.

Free of charge—No extra cost and no paperwork.

Expert Medical Opinions Advance Medical

Advance Medical provides members with access to the best health care possible by assisting patients with any and all healthcare questions. The benefit also provides access to medical opinions from world-leading experts without having to leave home.

No cost—This benefit is fully sponsored by SISC. It is available to members covered on SISC medical plans at no cost.

Convenient—Members can get started with a phone call.

24/7 Physician Access —Anytime, AnywhereMDLive

Our PPO and HMO members can consult with doctors and pediatricians over the phone or using online video for medical conditions such as cough, cold, fever, sore throat, flu, infection, bronchitis and children’s health issues. MDLive physicians can diagnose and prescribe medication when appropriate. Online behavioral health visits are also available for confidential sessions with a licensed therapist or psychiatrist.

Convenient—24/7 access, including holidays.

Fast—No waiting to schedule an appointment or get a prescription.

Saves money—More cost-effective than the emergency room.

Free Generic MedicationsCostco

On most pharmacy plans, our PPO and HMO members can get free generic medications at Costco and through Costco Mail Order (excludes certain pain and cough medications).

Easy—Members take prescriptions to Costco pharmacy; no need to be a Costco member.

SISC EAP

Call 1-800-999-7222

OR

Go to anthemEAP.com and enter SISC.

All employees at member districts (including Kaiser)

All SISC members (including Kaiser)

Anthem and Blue Shield PPO and HMO

Anthem and Blue Shield PPO and HMO (participating plans)

Retirees enrolled in individual retiree plans are not eligible for these services. Kaiser members are not included in the MDLive and Costco free generic programs.

These programs are not available to retired Medicare members.

lonickellTypewritten TextNot Applicable to Kaiser Members

lonickellTypewritten TextNot Applicable to Kaiser Members

Before your visitGet a cost estimate

During your visitKnow what to expect

After your visitManage your bills and costs

Paying for care

Your deductible plan works a little differently than a traditional HMO plan. But you get the same quality care and convenience you expect from Kaiser Permanente.

With your plan, you’ll pay the full charges for most covered services until you reach your deductible. Then you’ll start paying less — generally, a coinsurance. * The steps in this brochure show what happens before, during, and after each visit — so you can avoid surprises and better understand and manage your health care costs.

Kaiser Permanente Deductible Plan Members

You can get an estimate of your costs anytime at kp.org/costestimates. See the next page for details.

*Depending on your plan, you may pay copays or coinsurance for some services without having to reach your deductible.

During your visit Know what to expect

Before your visit Get a cost estimate

Use our online Estimates toolVisit kp.org/costestimates for an estimate of what you’ll pay for many common services. Estimates are based on your plan benefits and whether you’ve reached your deductible — so you get personalized information every time.

Call us for an estimateIf you can’t get an estimate for a service online, call 303-338-3025 or 1-877-803-1929 (TTY 711), weekdays from 8 a.m. to 6 p.m.

After your visit Manage your bills and costs

Understanding your billsYou’ll get a bill after most visits. It will show the charges for the services you got, what you paid, what your health plan paid, and the amount you owe. Depending on the care you received, you may get a physician bill, a hospital bill, or both. If you’ve signed up for electronic billing, you’ll get an email alert instead of a paper bill.

Paying your billYou have several convenient options:

• Online: The easiest way to pay is to visit kp.org/paymedicalbills. You can securely pay your bill anytime.

• By mail: Send your payment in the return envelope that came with your bill.

• By phone: Call Member Services, weekdays from 8 a.m. to 6 p.m.

• In person: You can pay at a Kaiser Permanente medical office.

Tracking your expensesOn kp.org, you can access the status of your eligibility and a list of covered benefits. You are also able to see what your deductible and out-of-pocket maximum limits are. Once you reach your deductible, you’ll pay a copay or coinsurance for covered services instead of the full charges. If you reach your out-of-pocket maximum, you won’t pay for covered services for the rest of the year.*

• Visit kp.org/costestimates: It’s a quick, easy way to check your progress toward reaching your deductible and out-of-pocket maximum.

• Track your costs online, anytime: Sign on to kp.org and go to My Coverage and Costs to see your claims summary. It lists the charges for services you’ve received.

Visit kp.org/choosepaperless to switch to electronic bills, EOBs, and more. *Depending on your plan, preventive care services are covered at no cost or at a copay. For more information, see your Evidence of Coverage.

Make a payment when you check inWhen you come in for care, you’ll be asked to make a payment for your scheduled services. Your payment may only cover part of what you owe for your visit, especially if you get any additional services. In that case, you’ll get a bill for the difference later.

Expect a bill for additional servicesDuring your visit, your doctor may decide you also need services that weren’t scheduled — like a blood test or an X-ray. When you go to the lab or Radiology Department, you’ll make a payment for these services. If what you pay at check-in doesn’t cover everything you owe, you’ll get a bill later.

Costs for non-preventive carePreventive care services are a good way to catch health problems early. That’s why they’re covered at no cost or at a copay.* But sometimes when you come in for preventive care, you’ll get non-preventive services too. For example, during a routine physical exam, your doctor might remove a mole for testing. Because mole removal and testing are non-preventive, you’ll get a bill for them later. * Depending on your plan, for a small number of services, you may need to keep paying copays or coinsurance after reaching

your out-of-pocket maximum.

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Do you have an HRA, HSA, or FSA?You can use the money in your health reimbursement arrangement (HRA), health savings account (HSA), or flexible spending account (FSA) to pay for care.* Just use the debit card for your account, if you have one, when you check in for your visit or when paying a bill later. Be sure to keep all receipts, bills, and EOBs in case you need to document your expenses later.

Have questions or need help paying for care?If you have questions about your costs or bills, call Medical Financial Counseling Services at 303-338-3025 or 1-877-803-1929 (TTY 711), weekdays from 8 a.m. to 6 p.m. You can also get information about financial assistance and payment options for members who need help paying for care.

Additional resources

*�You�can�use�your�HRA,�HSA,�or�FSA�to�pay�for�qualified�medical�expenses,�which�are�defined�under�Internal�Revenue�Code�Section�213(d)�in�IRS�Publication�502,�Medical and Dental Expenses, available at irs.gov/publications. Your employer may limit�which�qualified�medical�expenses�HRA�funds�can�be�used�for.

† For�HSA-qualified�plans,�once�you�reach�your�out-of-pocket�maximum,�you�won’t�have�to�pay�anything�for�covered�services�for the rest of the year.

Important termsHere are some terms to help you understand your plan. See your Evidence of Coverage for your plan details, including the date your deductible and out-of-pocket maximum will start over.

Deductible: The amount you pay each year for covered services before Kaiser Permanente starts paying. Depending on your plan, you may pay copays or coinsurance for some services without having to reach your deductible.

Copay: The set amount you pay for covered services — for example, a $10 copay for an office visit.

Coinsurance: A percentage of the charges that you pay for covered services. For example, a 20% coinsurance for a $200 procedure means you pay $40.

Out-of-pocket maximum: The maximum amount you’ll pay for covered services each year. For a small number of services, you may need to keep paying copays or coinsurance after reaching your out-of-pocket maximum.†