ImportantQuestions Answers WhythisMatters:

Whatistheoveralldeductible?

$7,350individual/$14,700family

Generally,youmustpayallthecostsfromprovidersuptothedeductibleamountbeforethisplanbeginstopay.Ifyouhaveotherfamilymembersontheplan,eachfamilymembermustmeettheirownindividualdeductibleuntilthetotalamountofdeductibleexpensespaidbyallfamilymembersmeetstheoverallfamilydeductible.

Arethereservicescoveredbeforeyoumeetyourdeductible?

Yes.Preventivecare,pre-andpost-natalcare,andtelemedicine.

Thisplancoverssomeitemsandservicesevenifyouhaventyetmetthedeductibleamount.Butacopaymentorcoinsurancemayapply.Forexample,thisplancoverscertainpreventiveserviceswithoutcostsharingandbeforeyoumeetyourdeductible.Seealistofcoveredpreventiveservicesathttps://www.healthcare.gov/coverage/preventive-care-benefits/.

Arethereotherdeductiblesforspecificservices?

No. Youdon'thavetomeetdeductiblesforspecificservices.

Whatistheout-of-pocketlimitforthisplan?

Yes.$7,350individual/$14,700family

Theout-of-pocketlimitisthemostyoucouldpayinayearforcoveredservices.Ifyouhaveotherfamilymembersinthisplan,theoverallfamilyout-of-pocket-limitmustbemet.

Whatisnotincludedintheout-of-pocketlimit?

Premiums,Balancebilledcharges,andhealthcarethisplandoesnotcover.

Eventhoughyoupaytheseexpenses,theydontcounttowardtheout-of-pocketlimit.

Willyoupaylessifyouuseanetworkprovider?

Yes.Seewww.hioscar.comorcall1-855-OSCAR-55foralistofIn-Networkproviders.

Thisplanusesaprovidernetwork.Youwillpaylessifyouuseaproviderintheplan'snetwork.Youwillpaythemostifyouuseanout-of-networkprovider,andyoumightreceiveabillfromaproviderforthedifferencebetweentheprovider'schargeandwhatyourplanpays(balancebilling).Beawareyournetworkprovidermightuseanout-of-networkproviderforsomeservices(suchaslabwork).Checkwithyourproviderbeforeyougetservices.

Doyouneedareferraltoseeaspecialist?

No. Youcanseethespecialistyouchoosewithoutareferral.

SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatYouPayForCoveredServices CoveragePeriod:01/01/2018-12/31/2018SimpleBronzePlan Coveragefor:Individual+FamilyPlanType:EPO

TheSummaryofBenefitsandCoverage(SBC)documentwillhelpyouchooseahealthplan.TheSBCshowsyouhowyouandtheplanwouldsharethecostforcoveredhealthcareservices.NOTE:Informationaboutthecostofthisplan(calledthepremium)willbeprovidedseparately.Thisisonlyasummary.Formoreinformationaboutyourcoverage,ortogetacopyofthecompletetermsofcoverage,call1-855-OSCAR-55orvisithttps://www.hioscar.com/forms/?planState=NY&planDate=2018.Forgeneraldefinitionsofcommonterms,suchasallowedamount,balancedbilling,coinsurance,copayment,deductible,provider,orotherunderlinedtermsseetheGlossary.YoucanviewtheGlossaryatwww.dol.gov/ebsa/healthreformorcall1-855-OSCAR-55torequestacopy.

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CommonMedicalEvent ServicesYouMayNeed

WhatYouWillPayLimitations,Exceptions,&OtherImportantInformationYourCostIfYouUsean

In-networkProviderYourCostIfYouUseanOut-of-networkProvider

Ifyouvisitahealthcareprovidersofficeorclinic

Primarycarevisittotreataninjuryorillness

$0copay/visit NotCovered PCPvisitsattheOscarCenterarecoveredinfull.

Specialistvisit $0copay/visit NotCovered none

Preventivecare/screening/immunization $0copay/visit NotCovered

Deductibledoesnotapply.Youmayhavetopayforservicesthataren'tpreventive.Askyourprovideriftheservicesyouneedarepreventive.Thencheckwhatyourplanwillpayfor.

Ifyouhaveatest

Diagnostictest(x-ray,bloodwork) $0copay/visit(x-ray),$0copay/visit(labwork)

NotCovered

Preauthorizationisrequiredfordiagnosticradiology(exceptx-ray).Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.

Imaging(CT/PETscans,MRIs) $0copay/visit NotCoveredPreauthorizationisrequired.Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.

Allcopaymentandcoinsurancecostsshowninthischartareafteryourdeductiblehasbeenmet,ifadeductibleapplies.

*Formoreinformationaboutlimitationsandexceptions,seetheplanorpolicydocumentatwww.hioscar.com. 2of9

CommonMedicalEvent ServicesYouMayNeed

WhatYouWillPayLimitations,Exceptions,&OtherImportantInformationYourCostIfYouUsean

In-networkProviderYourCostIfYouUseanOut-of-networkProvider

Ifyouneeddrugstotreatyourillnessorcondition

Moreinformationaboutprescriptiondrugcoverageisavailableatwww.hioscar.com/search/NY/drugs?year=2018

Genericdrugs(Tier1)

$0copay/prescription(retail),$0copay/prescription(mailorder)

NotCovered

Coversupto30daysupplyatretailandupto90daysupplyformailorder.Preauthorization/steptherapymayberequired.

Preferredbranddrugs(Tier2)

$0copay/prescription(retail),$0copay/prescription(mailorder)

NotCovered

Coversupto30daysupplyatretailandupto90daysupplyformailorder.Preauthorization/steptherapymayberequired.

Non-preferredbranddrugs(Tier3)

$0copay/prescription(retail),$0copay/prescription(mailorder)

NotCovered

Coversupto30daysupplyatretailandupto90daysupplyformailorder.Preauthorization/steptherapymayberequired.

Specialtydrugs(Tier4)

$0copay/prescription(retail),$0copay/prescription(mailorder)

NotCovered

Coversupto30daysupplythroughOscarSpecialtyPharmacy.Preauthorization/steptherapymayberequired

Ifyouhaveoutpatientsurgery

Facilityfee(e.g.,ambulatorysurgerycenter)

$0copay/visit NotCovered none

Physician/surgeonfees $0copay/visit NotCoveredPreauthorizationrequired.Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.

*Formoreinformationaboutlimitationsandexceptions,seetheplanorpolicydocumentatwww.hioscar.com. 3of9

CommonMedicalEvent ServicesYouMayNeed

WhatYouWillPayLimitations,Exceptions,&OtherImportantInformationYourCostIfYouUsean

In-networkProviderYourCostIfYouUseanOut-of-networkProvider

Ifyouneedimmediatemedicalattention

Emergencyroomcare

$0copay/visit(ERFacilityFee),$0copay/visit(ERPhysicianFee)

$0copay/visit(ERFacilityFee),$0copay/visit(ERPhysicianFee)

none

Emergencymedicaltransportation $0copay/visit $0copay/visit none

Urgentcare $100.00copay/visit NotCovered

Preauthorizationisrequiredforout-of-networkurgentcare.Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.Deductibledoesnotapply.

Ifyouhaveahospitalstay

Facilityfee(e.g.,hospitalroom) $0copay/visit NotCovered

Preauthorizationisrequiredforinpatientstays,exceptforemergencyadmissions.Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.

Physician/surgeonfees $0copay/visit NotCoveredPreauthorizationrequired.Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.

Ifyouneedmentalhealth,behavioralhealth,orsubstanceabuseservices

Mental/Behavioralhealthoutpatientservices

$0copay/visit(officevisit),$0copay/visit(forotheroutpatientservices)

NotCoveredPreauthorizationmayberequired.Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.

Mental/Behavioralhealthinpatientservices

$0copay/visit NotCovered

Preauthorizationisrequiredforinpatientstays,exceptforemergencyadmissionsorparticipatingOASAS-certifiedfacilities.Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.

*Formoreinformationaboutlimitationsandexceptions,seetheplanorpolicydocumentatwww.hioscar.com. 4of9

CommonMedicalEvent ServicesYouMayNeed

WhatYouWillPayLimitations,Exceptions,&OtherImportantInformationYourCostIfYouUsean

In-networkProviderYourCostIfYouUseanOut-of-networkProvider

Ifyouarepregnant

OfficeVisits $0copay/visit NotCovered Cost-sharingdoesnotapplytocertainpreventiveservices.Dependingonthetypeofservices,cost-sharingmayapply.MaternitycaremayincludetestsandservicesdescribedelsewhereintheSBC(i.e.ultrasound).

Childbirth/deliveryprofessionalservices

$0copay/visit NotCovered

Childbirth/deliveryfacilityservices $0copay/visit NotCovered

Preauthorizationisnotrequiredifpatientstay

CommonMedicalEvent ServicesYouMayNeed

WhatYouWillPayLimitations,Exceptions,&OtherImportantInformationYourCostIfYouUsean

In-networkProviderYourCostIfYouUseanOut-of-networkProvider

Ifyouneedhelprecoveringorhaveotherspecialhealthneeds

Hospiceservice $0copay/visit NotCovered

Upto210daysperyear.Inpatienthospicecareissubjecttotheinpatienthospitalcost-sharing.Preauthorizationmayberequired.Ifyoudon'tgetpreauthorization,paymentforcaremaybedenied.

Ifyourchildneedsdentaloreyecare

Children'seyeexam $0copay/visit NotCovered 1examina12monthperiod

Children'sglasses $0copay/visit NotCovered 1pairofglassesorcontactlensesina12monthperiod

Children'sdentalcheck-up $0copay/visit NotCovered Limitedto2preventivedentalcheckupsperyear.Deductibledoesnotapply.

*Formoreinformationaboutlimitationsandexceptions,seetheplanorpolicydocumentatwww.hioscar.com. 6of9

ExcludedServices&OtherCoveredServices:

ServicesYourPlanGenerallyDoesNOTCover(Checkyourpolicyorplandocumentformoreinformationandalistofanyotherexcludedservices.)

Cosmeticservices

Dentalcare

Long-termcare

Non-emergencycarewhentravelingoutsidetheU.S.

Private-dutynursing

Routineeyecare(Adult)

Routinefootcare

Weightlossprograms

OtherCoveredServices(Limitationsmayapplytotheseservices.Thisisntacompletelist.Pleaseseeyourplandocument.)

Abortion

Acupuncture

Bariatricsurgery

Chiropracticcare

Hearingaids

Infertilitytreatment

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YourRightstoContinueCoverage:

Thereareagenciesthatcanhelpifyouwanttocontinueyourcoverageafteritends.Thecontactinformationforthoseagenciesis:DepartmentofLabor'sEmployeeBenefitsSecurityAdministrationat1-866-444-EBSA(3272)orwww.dol.gov/ebsa/healthreform.Othercoverageoptionsmaybeavailabletoyoutoo,includingbuyingindividualinsurancecoveragethroughtheHealthInsuranceMarketplace.FormoreinformationabouttheMarketplace,visitwww.HealthCare.govorcall1-800-318-2596.

YourGrievanceandAppealsRights:

Thereareagenciesthatcanhelpifyouhaveacomplaintagainstyourplanforadenialofaclaim.Thiscomplaintiscalledagrievanceorappeal.Formoreinformationaboutyourrights,lookattheexplanationofbenefitsyouwillreceiveforthatmedicalclaim.Yourplandocumentsalsoprovidecompleteinformationtosubmitaclaim,appeal,oragrievanceforanyreasontoyourplan.Formoreinformationaboutyourrights,thisnotice,orassistance,contact:DepartmentofLabor'sEmployeeBenefitsSecurityAdministrationat1-866-444-EBSA(3272)orwww.dol.gov/ebsa/healthreform.Additionally,aconsumerassistanceprogramcanhelpyoufileyourappeal.Contactwww.communityhealthadvocates.org.Ifyouhaveacomplaintoraredissatisfiedwithadenialofcoverageforclaimsunderyourplan,youmaybeabletoappealorfileagrievance.Forquestionsaboutyourrights,thisnotice,orassistance,youcancontactwww.communityhealthadvocates.org.

DoesthisplanprovideMinimumEssentialCoverage?Yes

IfyoudonthaveMinimumEssentialCoverageforamonth,youllhavetomakeapaymentwhenyoufileyourtaxreturnunlessyouqualifyforanexemptionfromtherequirementthatyouhavehealthcoverageforthatmonth.

DoesthisplanmeettheMinimumValueStandards?Yes

IfyourplandoesntmeettheMinimumValueStandards,youmaybeeligibleforapremiumtaxcredittohelpyoupayforaplanthroughtheMarketplace.

LanguageAccessServices:

Spanish(Espaol):ParaobtenerasistenciaenEspaol,llameal1-855-OSCAR-55.

IfyouwouldlikeassistanceinanotherlanguagepleasecallOscarmemberservicesat1-855-OSCAR-55,whichhasaccesstothirdpartytranslationservices.

Toseeexamplesofhowthisplanmightcovercostsforasamplemedicalsituation,seethenextpage.

*Formoreinformationaboutlimitationsandexceptions,seetheplanorpolicydocumentatwww.hioscar.com. 8of9

AbouttheseCoverageExamples:

PegisHavingaBaby(9monthsofin-networkpre-natalcareand

ahospitaldelivery)

Theplan'soveralldeductible:$7,350

Specialist:$0copay/visit

Hospital(facility):$0copay/visit

Other:$0copay/visit

ThisEXAMPLEeventincludesserviceslike:Specialistofficevisits(prenatalcare)Childbirth/DeliveryProfessionalServicesChildbirth/DeliveryFacilityServicesDiagnostictests(ultrasoundsandbloodwork)Specialistvisit(anesthesia)Total $7,500

Inthisexample,Pegwouldpay:CostSharing

Deductibles $6,300

Copays $0

Coinsurance $0

Whatisn'tcovered

Limitsorexclusions $200

Total $6,500

ManagingJoe'sType2Diabetes(ayearofroutinein-networkcareofawell-

controlledcondition)

Theplan'soveralldeductible:$7,350

Specialist:$0copay/visit

Hospital(facility):$0copay/visit

Other:$0copay/visit

ThisEXAMPLEeventincludesserviceslike:Primarycarephysicianofficevisits(includingdiseaseeducation)Diagnostictests(bloodwork)PrescriptiondrugsDurablemedicalequipment(glucosemeter)Total $5,400

Inthisexample,Joewouldpay:CostSharing

Deductibles $5,100

Copays $0

Coinsurance $0

Whatisn'tcovered

Limitsorexclusions $80

Total $5,200

Mia'sSimpleFracture(in-networkemergencyroomvisitand

followupcare)

Theplan'soveralldeductible:$7,350

Specialist:$0copay/visit

Hospital(facility):$0copay/visit

Other:$0copay/visit

ThisEXAMPLEeventincludesserviceslike:Emergencyroomcare(includingmedicalsupplies)Diagnostictest(x-ray)Durablemedicalequipment(crutches)Rehabilitationservices(physicaltherapy)Total $1,925

Inthisexample,Miawouldpay:CostSharing

Deductibles $1,800

Copays $100

Coinsurance $0

Whatisn'tcovered

Limitsorexclusions $0

Total $1,900

Thisisnotacostestimator.Treatmentsshownarejustexamplesofhowthisplanmightcovermedicalcare.Youractualcostswillbedifferentdependingontheactualcareyoureceive,thepricesyourproviderscharge,andmanyotherfactors.Focusonthecostsharingamounts(deductibles,copaymentsandcoinsurance)andexcludedservicesundertheplan.Usethisinformationtocomparetheportionofcostsyoumightpayunderdifferenthealthplans.Pleasenotethesecoverageexamplesarebasedonself-onlycoverage.

TheplanwouldberesponsiblefortheothercostsoftheseEXAMPLEcoveredservices. 9of9

HIOSCAR.COM

Non-Discrimination

Notice of Non-Discrimination: Discrimination is Against the Law Oscar complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Oscar does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Oscar: 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 Member Services at 1-855-OSCAR-55 (TTY: 7-1-1).

If you believe that Oscar 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:

NY/NJ/TX/OH/TN Members: Oscar Insurance, Attention Grievances PO Box 52146, Phoenix AZ, 85072

CA Members: Oscar Health Plan of California, Attention Grievances 9942 Culver City Blvd., PO Box 1279, Culver City, CA 90232

1-855-OSCAR-55 (TTY: 7-1-1), Mon - Fri 8 am - 8 pm/ Sat - Sun 9 am - 5 pm (EST), Fax: 1-888-977-2062, Email: help@hioscar.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Oscars Grievances Department 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, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

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

Language Assistance Services for the Deaf or Hard of Hearing

ATTENTION: If you are deaf or hard of hearing, talk to text services, free of charge, are available to you. Call 1-855-Oscar-55 and dial 711 to receive TTY/TDD services.

Albanian Nse ju, ose dikush q po ndihmoni, ka pyetje pr Oscar, keni t drejt t merrni ndihm dhe informacion falas n gjuhn tuaj. Pr t folur me nj prkthyes, telefononi numrin 1-855-OSCAR-55.

Arabic Oscar .OSCAR-55-855-1.

Armenian Oscar , 1-855-OSCAR-55

Bengali , , Oscar, , ---.

Chinese Oscar 1-855-OSCAR-55

Farsi Oscar . OSCAR-55-855-1.

French Si vous, ou une personne que vous aidez, a des questions propos d'Oscar, vous avez le droit d'obtenir de l'aide et des informations dans votre langue gratuitement. Pour parler un interprte, appelez le 1-855-OSCAR-55.

German Falls Sie oder jemand, dem Sie helfen, Fragen zu Oscar haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte 1-855-OSCAR-55 an.

Greek Oscar, . , 1-855-OSCAR-55.

Gujarati Oscar ,

. 1-855-OSCAR-55 . Haitian-Creole

Si oumenm oswa yon moun w ap ede gen kesyon konsnan Oscar, se dwa w pou resevwa asistans ak enfmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avk yon entprt, rele nan 1-855-OSCAR-55.

Hindi , Oscar , , 1-855-OSCAR-55

Hmong Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Oscar, koj muaj cai kom lawv muab cov ntsiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 1-855-OSCAR-55.

Italian Se tu o qualcuno che stai aiutando avete domande su Oscar, hai il diritto di ottenere aiuto e informazioni nella tua linguagratuitamente. Per parlare con un interprete, puoi chiamare 1-855-OSCAR-55.

Japanese Oscar1-855-OSCAR-55

.1-855-OSCAR-55

1-855-OSCAR-55

1-855-OSCAR-55

1-855-OSCAR-55

1-855-OSCAR-55

1-855-OSCAR-55.

1-855-OSCAR-55

Oscar

Oscar

Oscar,

Oscar

Oscar

Oscar

Oscar

Albanian Nse ju, ose dikush q po ndihmoni, ka pyetje pr Oscar, keni t drejt t merrni ndihm dhe informacion falas n gjuhn tuaj. Pr t folur me nj prkthyes, telefononi numrin 1-855-OSCAR-55.

Arabic Oscar .OSCAR-55-855-1.

Armenian Oscar , 1-855-OSCAR-55

Bengali , , Oscar, , ---.

Chinese Oscar 1-855-OSCAR-55

Farsi Oscar . OSCAR-55-855-1.

French Si vous, ou une personne que vous aidez, a des questions propos d'Oscar, vous avez le droit d'obtenir de l'aide et des informations dans votre langue gratuitement. Pour parler un interprte, appelez le 1-855-OSCAR-55.

German Falls Sie oder jemand, dem Sie helfen, Fragen zu Oscar haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte 1-855-OSCAR-55 an.

Greek Oscar, . , 1-855-OSCAR-55.

Gujarati Oscar ,

. 1-855-OSCAR-55 . Haitian-Creole

Si oumenm oswa yon moun w ap ede gen kesyon konsnan Oscar, se dwa w pou resevwa asistans ak enfmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avk yon entprt, rele nan 1-855-OSCAR-55.

Hindi , Oscar , , 1-855-OSCAR-55

Hmong Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Oscar, koj muaj cai kom lawv muab cov ntsiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 1-855-OSCAR-55.

Italian Se tu o qualcuno che stai aiutando avete domande su Oscar, hai il diritto di ottenere aiuto e informazioni nella tua linguagratuitamente. Per parlare con un interprete, puoi chiamare 1-855-OSCAR-55.

Japanese Oscar1-855-OSCAR-55

Khmer Oscar

1-855-OSCAR-55 Korean Oscar ,

. 1-855-OSCAR-55 . Laotian Oscar,

. , 1-855-OSCAR-55. Polish Jeli Ty lub osoba, ktrej pomagasz, macie pytania odnonie Oscar, macie prawo do uzyskania bezpatnej informacji i

pomocy we wasnym jzyku. Aby porozmawia z tumaczem, zadzwo pod numer 1-855-OSCAR-55.Punjabi , , Oscar , '

, 1-855-OSCAR-55 Russian , , Oscar,

. 1-855-OSCAR-55.

Spanish Si usted, o alguien a quien usted est ayudando, tiene preguntas acerca de Oscar, tiene derecho a obtener ayuda e informacin en su idioma sin costo alguno. Para hablar con un intrprete, llame al 1-855-OSCAR-55.

Tagalog Kung ikaw o ang iyong tinutulungan ay may mga tanong tungkol sa Oscar, may karapatan kang makatanggap ng libreng tulong at impormasyon nang nasa iyong wika. Upang makipag-usap sa isang tagasalin, tumawag sa 1-855-OSCAR-55.

Thai Oscar 1-855-OSCAR-55

Ukrainian , , OSCAR, . , 1-855-OSCAR-55.

Urdu / Oscar OSCAR-55-855-1

Vietnamese Nu qu v, hay ngi m qu v ang gip , c cu hi v Oscar, qu v s c quyn c gip v c thm thng tin bng ngn ng ca mnh min ph. ni chuyn vi mt thng dch vin, xin gi 1-855-OSCAR-55.

Yiddish , , , Oscar OSCAR-55-1-855 , .

1-855-OSCAR-551-855-OSCAR-55

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Oscar

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