Deductible inVentiv Health, Inc.: Choice Fund Open Access ...

inVentiv Health, Inc.: Choice Fund Open Access Plus HRA

Coverage Period: 01/01/2016 - 12/31/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage for: Individual/Individual + Family | Plan Type: OAP

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at

sp/ or by calling 1-855-281-1204

Important Questions

What is the overall deductible?

Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays?

Does this plan use a network of providers?

Answers For in-network providers $1,750 individual/ $2,500 individual+spouse or individual+child(ren)/ $3,250 family For out-of-network providers $1,750 individual/ $2,500 individual+spouse or individual+child(ren)/ $3,250 family Does not apply to in-network preventive care & immunizations, prescription drugs. Deductible per individual applies when the employee is the only individual covered under the plan Amount your employer contributes to your account: Up to $400 individual/ $900 individual+spouse or individual + child (ren)/ $1,400 family.

No.

Yes. For in-network providers $3,000 individual/ $4,500 individual+spouse or individual+child (ren)/ $6,000 family For out-of-network providers $4,000 individual/ $6,000 individual+spouse or individual+child(ren)/ $8,000 family Premium, balance-billed charges, penalties for no preauthorization, and health care this plan doesn't cover.

No.

Yes. For a list of participating providers, see or call 1-855-281-1204

Why this Matters:

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

Even though you pay these expenses, they don't count toward the out-ofpocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Questions: Call 1-855-281-1204 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at iio. or call 1-855-281-1204 to request a copy.

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Important Questions Do I need a referral to see a specialist?

Are there services this plan doesn't cover?

Answers No. You don't need a referral to see a specialist.

Yes.

Why this Matters:

You can see the specialist you choose without permission from this plan.

Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services.

Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health

plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charge is $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.

Common Medical Event

If you visit a health care provider's office or clinic

If you have a test

Services You May Need

Primary care visit to treat an injury or illness Specialist visit

Other practitioner office visit

Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)

Your Cost if you use an

In-Network Provider

Out-of-Network Provider

20% co-insurance

40% co-insurance

20% co-insurance

20% co-insurance for chiropractor

40% co-insurance 40% co-insurance

No charge

40% co-insurance

20% co-insurance

40% co-insurance

20% co-insurance

40% co-insurance

Limitations & Exceptions

-----------none---------------------none----------Coverage for Chiropractic care is limited to 20 days annual max. -----------none-----------

-----------none-----------

$400 penalty for no precert OON

Questions: Call 1-855-281-1204 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at iio. or call 1-855-281-1204 to request a copy.

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Common Medical Event Services You May Need

If you need drugs to treat your illness or condition

Generic drugs

Your Cost if you use an

In-Network Provider

Out-of-Network Provider

Retail: $7 copay Mail-Order: $17.50 copay

Not Covered

See for information on drugs covered by your plan. Not all drugs are covered. Prescription drug costs are subject to annual deductible.

Preferred brand drugs Non-preferred brand drugs Specialty drugs

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

If you have mental health, behavioral health, or substance abuse needs

Facility fee (e.g., ambulatory surgery center)

Physician/surgeon fees

Emergency room services

Emergency medical transportation

Urgent care

Facility fee (e.g., hospital room)

Physician/surgeon fees

Mental/Behavioral health outpatient services

Mental/Behavioral health inpatient services

Substance use disorder outpatient services

Substance use disorder inpatient services

Retail: $45 copay Mail-Order: $112.50 copay

Retail: $70 copay Mail-Order: $175 copay 5% coinsurance, minimum $75 copay 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance

20% co-insurance

20% co-insurance

20% co-insurance

Not Covered

Not Covered

N/A 40% co-insurance 40% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance

Limitations & Exceptions Mail-Order: Up to a 90 day supply Generic Contraceptives covered at No Charge. Mail-Order: Up to a 90 day supply Generic Contraceptives covered at No Charge. Mail-Order: Up to a 90 day supply Generic Contraceptives covered at No Charge.

$400 penalty for no precert OON $400 penalty for no precert OON -----------none---------------------none---------------------none----------$400 penalty for no precert OON $400 penalty for no precertification. $400 penalty for no precert OON

$400 penalty for no precert OON

$400 penalty for no precert OON

$400 penalty for no precert OON

Questions: Call 1-855-281-1204 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at iio. or call 1-855-281-1204 to request a copy.

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Common Medical Event If you are pregnant

Services You May Need

Prenatal and postnatal care Delivery and all inpatient services

Your Cost if you use an

In-Network Provider

Out-of-Network Provider

20% co-insurance

40% co-insurance

20% co-insurance

40% co-insurance

Home health care

20% co-insurance

40% co-insurance

If you need help recovering or have other special health needs

Rehabilitation services Habilitation services

20% co-insurance 20% co-insurance

Skilled nursing care

20% co-insurance

Durable medical equipment 20% co-insurance

Hospice services

20% co-insurance

If your child needs dental or eye care

Eye Exam

Glasses Dental check-up

Not Covered

Not Covered Not Covered

40% co-insurance

40% co-insurance

40% co-insurance 40% co-insurance 40% co-insurance Not Covered Not Covered Not Covered

Limitations & Exceptions

-----------none-----------

$400 penalty for no precert OON

$400 penalty for no precert OON. Coverage is limited to 120 days annual max. Maximums crossaccumulate. $400 penalty for failure to precert OON speech therapy services. Coverage is limited to annual max of: 60 days for Rehabilitation services; 36 days for Cardiac and Pulmonary rehab services Coverage for Habilitation services and Rehabilitation services are limited to 60 days annual maximum $400 penalty for no precert OON. Coverage is limited to 100 days annual max $400 penalty for no precert OON $400 penalty for no precert OON Vision screening done by your PCP as part of your Preventive Care visit is covered as a preventive screening -----------none---------------------none-----------

Questions: Call 1-855-281-1204 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at iio. or call 1-855-281-1204 to request a copy.

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Excluded Services & Other Covered Services

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)

Infertility treatment

Bariatric surgery Cosmetic surgery Routine Dental care (Adult) Routine Dental care (Children)

Long-term care Non-emergency care when traveling outside the U.S. Prescription drugs Private-duty nursing Routine eye care (Adult/Children)*

*Vision screening done by your PCP as part of your Preventive Care visit

Routine foot care Weight loss programs

is covered as a preventive screening

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Acupuncture Chiropractic care Hearing aids

Questions: Call 1-855-281-1204 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at iio. or call 1-855-281-1204 to request a copy.

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