UnitedHealthcare185 Asylum StreetCityplace IHartford, CT 06103

May 8, 2020

GA3X5988BW

ST. LOUIS CRISIS NURSERY11710 ADMINISTRATION DR SUITE 18SAINT LOUIS, MO 631460000

Dear Customer:

The Affordable Care Act requires all health plan issuers and group health plans to provide eligible enrollees with aSummary of Benefits and Coverage (SBC). The SBC provides you information to better understand your plan andallows you to compare coverage options.

You are receiving this package due to one of the following plan coverage events that requires you to receive anSBC.

Upon application for coverage,

Prior to any material modification of your plan coverage,

Prior to your plan renewal, or

You are a special enrollee.

If you are an Employer, you can find your group’s SBC documents by logging intowww.employereservices.com and select "Summary of Benefits and Coverage" under the Resources menu.

For more information regarding this document, please visit uhc.com/summary or contact the Member Servicesnumber on the back of your ID card.

Very truly yours,

Christopher HockUnitedHealthcare

ASFX 1 of 7

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2020 - 06/30/2021Core Essential ASFX /459 Coverage for: Employee/Family | Plan Type: EPO

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

www.welcometouhc.com or by calling 1-800-782-3740. 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.cciio.cms.gov orwww.dol.gov/ebsa/healthreform or call 1-866-487-2365 to request a copy.

ImportantQuestions Answers Why This Matters:

What is the overalldeductible?

Network: $3,000 Individual / $9,000 FamilyPer calendar year.

Generally, you must pay all of the costs from providers up to the deductibleamount before this plan begins to pay. If you have other family members on theplan, each family member must meet their own individual deductible until the totalamount of deductible expenses paid by all family members meets the overall familydeductible.

Are there servicescovered before youmeet yourdeductible?

Yes. Preventive care and categories with a copayare covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductibleamount. But a copayment or coinsurance may apply. For example, this plan coverscertain preventive services without cost-sharing and before you meet yourdeductible. See a list of covered preventive services atwww.healthcare.gov/coverage/preventive-care-benefits/.

Are there otherdeductibles forspecific services?

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

What is theout-of-pocket limitfor this plan?

Network: $6,700 Individual / $13,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. Ifyou have other family members in this plan, they have to meet their ownout-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not includedin the out-of-pocketlimit?

Premiums, balance-billing charges, and healthcare this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.

Will you pay less ifyou use a networkprovider?

Yes. See www.welcometouhc.com or call1-800-782-3740 for a list of network providers.

This plan uses a provider Network. You will pay less if you use a provider in theplan’s Network. You will pay the most if you use an out-of-Network provider, andyou might receive a bill from a provider for the difference between the provider’scharge and what your plan pays (balance billing). Be aware, your Network providermight use an out-of-Network provider for some services (such as lab work). Checkwith your provider before you get services.

Do you need areferral to see aspecialist?

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

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

CommonMedical Event Services You May Need

What You Will Pay

NetworkProvider (You

will pay theleast)

Out-of-NetworkProvider (Youwill pay the

most)

Limitations, Exceptions, & Other ImportantInformation

If you visit ahealth careprovider’s officeor clinic

Primary care visit to treat aninjury or illness

$10 copay pervisit, deductibledoes not apply

Not Covered Virtual visits (Telehealth) - No Charge by a Designated VirtualNetwork Provider.If you receive services in addition to office visit, additionalcopays, deductibles, or coinsurance may apply e.g. surgery.Children under age 19: No Charge.

Specialist visit $75 copay pervisit, deductibledoes not apply

Not Covered If you receive services in addition to office visit, additionalcopays, deductibles, or coinsurance may apply e.g. surgery.

Preventivecare/screening/immunizati-on

No Charge Not Covered Includes preventive health services specified in the health carereform law. You may have to pay for services that aren’tpreventive. Ask your provider if the services needed arepreventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, bloodwork)

50% coinsurance Not Covered None

Imaging (CT/PET scans,MRIs)

50% coinsurance Not Covered $250 per occurrence deductible applies prior to the overalldeductible.

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CommonMedical Event Services You May Need

What You Will Pay

NetworkProvider (You

will pay theleast)

Out-of-NetworkProvider (Youwill pay the

most)

Limitations, Exceptions, & Other ImportantInformation

If you need drugsto treat yourillness orcondition

More informationabout prescriptiondrug coverage isavailable at www.welcometouhc.com.

Tier 1 - Your Lowest-CostOption

Deductible doesnot apply. Retail:$10 copayMail-Order: $25copay

Not Covered Provider means pharmacy for purposes of this section.Retail: Up to a 31 day supply. Mail-Order*: 90 day supply or*Preferred 90 Day Retail Network pharmacy. If you use anout-of-Network pharmacy (including a mail order pharmacy),you may be responsible for any amount over the allowedamount.Copay is per prescription order up to the day supply limit listedabove.You may need to obtain certain drugs, including certain specialtydrugs, from a pharmacy designated by us.Certain drugs may have a preauthorization requirement or mayresult in a higher cost. You may be required to use a lower-costdrug(s) prior to benefits under your policy being available forcertain prescribed drugs.See the website listed for information on drugs covered by yourplan. Not all drugs are covered. Certain preventive medicationsand Tier 1 contraceptives are covered at No Charge.

Tier 2 - Your Midrange-CostOption

Deductible doesnot apply. Retail:$50 copayMail-Order: $125copay

Not Covered

Tier 3 - Your Midrange-CostOption

Deductible doesnot apply. Retail:$100 copayMail-Order: $250copay

Not Covered

Tier 4 - AdditionalHigh-Cost Options

Deductible doesnot apply. Retail:$250 copayMail-Order: $625copay

Not Covered

If you haveoutpatient surgery

Facility fee (e.g., ambulatorysurgery center)

50% coinsurance Not Covered $250 outpatient surgery per occurrence deductible applies priorto the overall deductible.

Physician/surgeon fees 50% coinsurance Not Covered NoneIf you needimmediatemedical attention

Emergency room care 50% coinsurance 50% coinsurance $250 Emergency per occurrence deductible applies prior to theoverall deductible.

Emergency medicaltransportation

50% coinsurance 50% coinsurance None

CommonMedical Event Services You May Need

What You Will Pay

NetworkProvider (You

will pay theleast)

Out-of-NetworkProvider (Youwill pay the

most)

Limitations, Exceptions, & Other ImportantInformation

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Urgent care $50 copay pervisit, deductibledoes not apply

Not Covered If you receive services in addition to urgent care visit, additionalcopays, deductibles, or coinsurance may apply e.g. surgery.

If you have ahospital stay

Facility fee (e.g., hospitalroom)

50% coinsurance Not Covered $250 Inpatient Stay per occurrence deductible applies prior tothe overall deductible.

Physician/surgeon fees 50% coinsurance Not Covered NoneIf you needmental health,behavioral health,or substanceabuse services

Outpatient services $10 copay pervisit, deductibledoes not apply

Not Covered Network partial hospitalization /intensive outpatient treatment:50% coinsurance

Inpatient services 50% coinsurance Not Covered NoneIf you arepregnant

Office visits No Charge Not Covered Cost sharing does not apply for preventive services. Dependingon the type of services, a copayment, deductibles, orcoinsurance may apply.

Childbirth/deliveryprofessional services

50% coinsurance Not Covered Maternity care may include tests and services describedelsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery facilityservices

50% coinsurance Not Covered $250 Inpatient Stay per occurrence deductible applies prior tothe overall deductible.

If you need helprecovering or haveother specialhealth needs

Home health care 50% coinsurance Not Covered Limited to 60 visits per calendar year.

Rehabilitation services $10 copay peroutpatient visit,deductible doesnot apply

Not Covered Limits per calendar year: Physical, Occupational, Pulmonary: 20visits each; Speech Unlimited. Cardiac 36 visits.

Habilitation services $10 copay peroutpatient visit,deductible doesnot apply

Not Covered Limits per calendar year: Physical & Occupational: 20 visits each,Speech: Unlimited.

Skilled nursing care 50% coinsurance Not Covered Skilled nursing is limited to 60 days per calendar year (combinedwith Inpatient Rehabilitation) .

CommonMedical Event Services You May Need

What You Will Pay

NetworkProvider (You

will pay theleast)

Out-of-NetworkProvider (Youwill pay the

most)

Limitations, Exceptions, & Other ImportantInformation

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Durable medical equipment 50% coinsurance Not Covered Covers 1 per type of Durable medical equipment (includingrepair/replace) every 3 years.

Hospice services 50% coinsurance Not Covered NoneIf your child needsdental or eye care

Children’s eye exam $10 copay pervisit, deductibledoes not apply

Not Covered Limited to 1 exam every 2 years.

Children’s glasses Not Covered Not Covered No coverage for Children’s glasses.Children’s dental check-up Not Covered Not Covered No coverage for Dental check-up.

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 excludedservices.)

Acupuncture Bariatric Surgery Cosmetic Surgery Dental Care (Adult/Child) Glasses

Infertility Treatment Long-Term Care Non-emergency care whentraveling outside the U.S.

Private Duty Nursing Routine Foot Care

Weight Loss Programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Chiropractic Care Hearing Aids Routine eye care (Adult) -1exam/24 months

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 thoseagencies is: 1-866-444-3272 or www.dol.gov/ebsa/healthreform for the U.S. Department of Labor, Employee Benefits Security Administration. You may alsocontact us at 1-800-782-3740 . Other coverage options may be available to you too, including buying individual insurance coverage through the HealthInsurance 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 iscalled a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plandocuments 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: 1-800-782-3740 ; or the Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform or the Missouri Department of Insurance at 1-800-726-7390 or insurance.mo.gov.

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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 exemptionfrom the requirement that you have health coverage for that month.

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 (Espa ol): Para obtener asistencia en Espa ol, llame al 1-800-782-3740 .Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-782-3740 .Chinese 1-800-782-3740 .Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-800-782-3740 .

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

The plan would be responsible for the other costs of these EXAMPLE covered services7 of 7

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 bedifferent depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharingamounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion ofcosts 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’s overall deductible $ 3,000Specialist copayment $75Hospital (facility) coinsurance 50%Other coinsurance 50%

This EXAMPLE event includes serviceslike:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

Total Example Cost $12,800

In this example, Peg would pay:Cost Sharing

Deductibles $3,000Copayments $0Coinsurance $3,400

What isn’t coveredLimits or exclusions $60The total Peg would pay is $6,460

Managing Joe’s type 2Diabetes

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

The plan’s overall deductible $ 3,000Specialist copayment $75Hospital (facility) coinsurance 50%Other coinsurance 50%

This EXAMPLE event includes serviceslike:Primary care physician office visits (includingdisease 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 $300Copayments $1,400Coinsurance $0

What isn’t coveredLimits or exclusions $30The total Joe would pay is $1,730

Mia’s Simple Fracture(in-network emergency room visit and

follow up care)

The plan’s overall deductible $ 3,000Specialist copayment $75Hospital (facility) coinsurance 50%Other coinsurance 50%

This EXAMPLE event includes serviceslike:Emergency room care (including medical supplies)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 $1,000Copayments $100Coinsurance $200

What isn’t coveredLimits or exclusions $0The total Mia would pay is $1,300

Notice of Non-DiscriminationWe do not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you cansend a complaint to the Civil Rights Coordinator.Online: UHC_Civil_Rights@uhc.comMail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help withyour complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC), TTY711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsfComplaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)Mail: U.S. Dept. of Health and Human Services.200 Independence Avenue, SW Room 509F, HHHBuilding Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or,you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefitsand Coverage (SBC), TTY 711, Monday through Friday, 8 a.m. to 8 p.m.