Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021-12/31/2021Robin with HealthPartners:Robin Oak Zero Cost Sharing Bronze Coverage for: Individual/Family | Plan Type: PPO

1 of 7

PSBC-IR623-210101

20173WI0130003-02

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare 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, call 1-877-838-4949 or visit us atwww.healthpartners.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-877-838-4949 to request a copy.Important Questions Answers Why This Matters:What is the overalldeductible?

Indian Health Care Provider (IHCP)or with IHCP referral at non-IHCP: $0 See the Common Medical Events chart below for your costs for services this plan covers.

Are there services coveredbefore you meet yourdeductible?

Not Applicable This plan does not have a deductible.

Are there other deductiblesfor specific services? No You don't have to meet deductibles for specific services.

What is the out-of-pocketlimit for this plan? None This plan does not have an out-of-pocket limit on your expenses.

https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#premiumhttps://www.healthcare.gov/sbc-glossary/#allowed-amounthttps://www.healthcare.gov/sbc-glossary/#balance-billinghttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossaryhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit

2 of 7

Important Questions Answers Why This Matters:What is not included in theout-of-pocket limit? This plan has no out-of-pocket limit. This plan does not have an out-of-pocket limit on your expenses.

Will you pay less if you usea network provider? No

This plan does not use a provider network. You can receive covered services from anyprovider.

Do you need a referral tosee a specialist? No You can see the in-network specialist you choose without a referral.

CommonMedical Event

Services You May Need What You Will Pay Limitations, Exceptions, and OtherImportant Information

If you visit a healthcare provider’soffice or clinic

Primary care visit to treat an injury or illnessPrimary Office Visit: No chargeConvenience Care: No chargeVirtuwell: No charge

None

Specialist visit No charge NonePreventive care/screening/immunization No charge None

If you have a test Diagnostic test (x-ray, blood work) No charge NoneImaging (CT/PET scans, MRIs) No charge NoneIf you need drugsto treat your illnessor conditionMore informationabout prescriptiondrug coverage isavailable athealthpartners.com/genericsadvantagerx

Generic drugs Formulary: No chargeNon-formulary: No charge

30 day supply retail / 90 day supply mailorder.

Formulary brand drugs No charge NoneNon-formulary brand drugs No charge None

Specialty drugs No charge None

If you haveoutpatient surgery

Facility fee (e.g., ambulatory surgery center) No charge NonePhysician/surgeon fees No charge None

If you needimmediate medicalattention

Emergency room care No charge NoneEmergency medical transportation No charge NoneUrgent care No charge None

If you have ahospital stay

Facility fee (e.g., hospital room) No charge NonePhysician/surgeon fees No charge None

If you need mentalhealth, behavioralhealth, orsubstance abuseneeds

Outpatient services No charge None

Inpatient services No charge None

https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#out-of-pocket-limithttps://www.healthcare.gov/sbc-glossary/#network-providerhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#networkhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#referralhttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#referralhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#preventive-carehttps://www.healthcare.gov/sbc-glossary/#screeninghttps://www.healthcare.gov/sbc-glossary/#diagnostic-testhttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttp://www.healthpartners.com/genericsadvantagerxhttp://www.healthpartners.com/genericsadvantagerxhttps://www.healthcare.gov/sbc-glossary/#formularyhttps://www.healthcare.gov/sbc-glossary/#Non-formularyhttps://www.healthcare.gov/sbc-glossary/#specialty-drughttps://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-serviceshttps://www.healthcare.gov/sbc-glossary/#emergency-medical-transportationhttps://www.healthcare.gov/sbc-glossary/#urgent-care

3 of 7

CommonMedical Event

Services You May Need What You Will Pay Limitations, Exceptions, and OtherImportant Information

If you are pregnantOffice visits No charge NoneChildbirth/delivery professional services No charge NoneChildbirth/delivery facility services No charge None

If you need helprecovering or haveother specialhealth needs

Home health care No charge 60 visits per calendar year

Rehabilitation services No charge Limited to 20 visits each per calendaryear

Habilitation services No charge Limited to 20 visits each per calendaryearSkilled nursing care No charge 120 days per calendar yearDurable medical equipment No charge None

Hospice services No chargeRespite care is limited to 5 days perepisode and respite care and continuouscare combined are limited to 30 days perepisode.

If your child needsdental or eye care

Children’s eye exam No charge None

Children’s glasses No chargeLimited to one pair of eyeglasses(lenses and frames) or one pair ofcontact lenses per calendar year.

Children’s dental check-up Not covered None

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 Infertility treatment Routine eye care (Adult) Bariatric surgery Long-term care Routine foot care Cosmetic surgery Non-emergency care when traveling outside the U.S. Termination of pregnancy, except in cases of

rape, incest, or danger to the life of the mother. Dental care (Adult) (and children) Private-duty nursing 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 (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 thoseagencies is: Your plan at 1-800-883-2177, or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at1-877-267-2323 x61565 or www.cciio.cms.gov or the Wisconsin Office of the Commissioner of Insurance at 608-266-0103 / 1-800-236-8517. Other coverage optionsmay 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.

https://www.healthcare.gov/sbc-glossary/#home-health-carehttps://www.healthcare.gov/sbc-glossary/#rehabilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#habilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#skilled-nursing-carehttps://www.healthcare.gov/sbc-glossary/#durable-medical-equipmenthttps://www.healthcare.gov/sbc-glossary/#hospice-serviceshttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#marketplacehttps://www.healthcare.gov/sbc-glossary/#marketplace

4 of 7

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 agrievanceor appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide 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: Your plan at 1-800-883-2177 or the Wisconsin Office of the Commissioner of Insurance at 608-266-0103 / 1-800-236-8517. Additionally, a consumerassistance program can help you file your appeal. Contact the Wisconsin Office of the Commissioner of Insurance at 608-266-0103 / 1-800-236-8517.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 premiumtax credit.Does this plan meet Minimum Value Standards? Not Applicable.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 1-877-838-4949.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-838-4949.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-838-4949.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-838-4949.

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

https://www.healthcare.gov/sbc-glossary/#grievancehttps://www.healthcare.gov/sbc-glossary/#appealhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#claimhttps://www.healthcare.gov/sbc-glossary/#grievancehttps://www.healthcare.gov/sbc-glossary/#appealhttps://www.healthcare.gov/sbc-glossary/#claimhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#claimhttps://www.healthcare.gov/sbc-glossary/#appealhttps://www.healthcare.gov/sbc-glossary/#grievancehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#appealhttps://www.healthcare.gov/sbc-glossary/#minimum-essential-coveragehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#health-insurancehttps://www.healthcare.gov/sbc-glossary/#marketplacehttps://www.healthcare.gov/sbc-glossary/#minimum-essential-coveragehttps://www.healthcare.gov/sbc-glossary/#premium-tax-creditshttps://www.healthcare.gov/sbc-glossary/#premium-tax-creditshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#minimum-value-standardhttps://www.healthcare.gov/sbc-glossary/#premium-tax-creditshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#marketplacehttps://www.healthcare.gov/sbc-glossary/#plan

5 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 portionof 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)

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)

The plan’s overall deductible None The plan’s overall deductible None The plan’s overall deductible None Specialist coinsurance 0% Specialist coinsurance 0% Specialist coinsurance 0% Hospital (facility)coinsurance

0% Hospital (facility)coinsurance

0% Hospital (facility)coinsurance

0%

Other coinsurance 0% Other coinsurance 0% Other coinsurance 0%

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

This EXAMPLE event includes services like:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)

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 $12,800 Total Example Cost $5,600 Total Example Cost $2,800

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost Sharing

Deductibles $0 Deductibles* $0 Deductibles* $0Copayments $0 Copayments $0 Copayments $0Coinsurance $0 Coinsurance $0 Coinsurance $0

What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $0 Limits or exclusions $0 Limits or exclusions $0The total Peg would pay is $0 The total Joe would pay is $0 The total Mia would pay is $0

Note: These numbers assume that the patient received care from an IHCP provider or with IHCP referral at a non-IHCP. If you receive care from a non-IHCP providerwithout a referral from an IHCP your costs may be higher.

https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#cost-sharinghttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#diagnostic-testhttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#primary care physicianhttps://www.healthcare.gov/sbc-glossary/#diagnostic-testhttps://www.healthcare.gov/sbc-glossary/#Prescription drugshttps://www.healthcare.gov/sbc-glossary/#durable-medical-equipmenthttps://www.healthcare.gov/sbc-glossary/#emergency room carehttps://www.healthcare.gov/sbc-glossary/#diagnostic-testhttps://www.healthcare.gov/sbc-glossary/#durable-medical-equipmenthttps://www.healthcare.gov/sbc-glossary/#rehabilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#cost sharinghttps://www.healthcare.gov/sbc-glossary/#cost sharinghttps://www.healthcare.gov/sbc-glossary/#cost sharinghttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurance

6 of 7

7 of 7