UNDERWRITTEN BY OPTIMA HEALTH PLAN

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1 Optima Vantage Equity Bronze 5300/40% Small Group Off Exchange Summary of Benefits HIOS Product ID: 20507VA This document is not a contract or policy with Optima Health. It is a summary of benefits and services available through the Plan. If there are any differences between this summary and the Coverage Policy, the provisions of that document will prevail for all benefits, conditions, limitations and exclusions. Some benefits require Pre-Authorization before You receive them. For details about Pre-Authorization, Covered Services, and Non-Covered Services please read Your entire Evidence of Coverage document carefully. Except for Emergency Services You must use In-Network Plan Providers for Your Covered Services. Deductible 3 $5,300 per Individual per Contract Year $10,600 per Family per Contract Year The individual Deductible can be met by a Member covered under an individual policy or a covered family member under a family policy. Maximum Out-of-Pocket Limit 4 $6,550 per Individual per Contract Year $13,100 per Family per Contract Year The individual maximum can be met by a Member covered under an individual policy or a covered family member under a family policy. Physician Office Visits Your Copayment or Coinsurance applies to Covered Services done during an office visit. You will pay an additional Copayment or Coinsurance for outpatient Habilitative and Rehabilitative therapy and services, injectable and infused medications, allergy care, testing and serum, outpatient advanced imaging procedures, and sleep studies done during an office visit. Pre-Authorization is required for in-office surgery 5. Primary Care Physician (PCP) and Specialist Physician Visits Primary Care Physician (PCP) Office Visit Also includes Virtual Consults when provided by an Optima Health approved provider. Specialist Office Visit Routine Annual Physical Exam Well Baby and Child Exams Annual Gynecological Exams and Pap Smears 9 PSA Tests Colorectal Cancer Tests Routine Adult and Childhood Immunizations Screening Colonoscopy Screening Mammograms Women s Preventive Services Preventive Care 8 Covered at 100%. Outpatient Rehabilitative and Habilitative Therapy and Services You Pay a Copayment or Coinsurance amount for services done in a Physician s office, a free-standing outpatient facility, or a hospital outpatient facility. Visit limits for physical, occupational, and speech therapy will not apply if You get that care as part of the Hospice or Early Intervention benefit. When You get physical, occupational, speech therapy in the home, the Home Health Visit limit will apply instead of the Therapy Services limits listed below. Therapy Services 6 Rehabilitative Services Physical Therapy/Occupational Therapy Services are limited to a maximum benefit of 30 visits per contract year. 6 Habilitative Services Physical Therapy/Occupational Therapy Services are limited to a maximum benefit of 30 visits per contract year. 6 1

2 Rehabilitative Services Speech Therapy Services are limited to a maximum benefit of 30 visits per contract year. 6 Habilitative Services Speech Therapy Services are limited to a maximum benefit of 30 visits per contract year. 6 Other Rehabilitative and Habilitative Services and Therapies 6 Cardiac Rehabilitation Pulmonary Rehabilitation Vascular Rehabilitation Vestibular Rehabilitation Private Duty Nursing 6 Includes services provided by an RN or LPN in the home limited to 16 hours per contract year. 6 Chemotherapy Radiation Therapy IV Therapy Inhalation Therapy Pre-Authorized Injectable and Infused Medications Includes injectable and infused medications, biologics, and IV therapy medications that require prior authorization. Coinsurance applies when medications are provided in a Physician s office, an outpatient facility, or in the Member s home as part of Skilled Home Health Care Services benefit. Coinsurance is in addition to any applicable office visit or outpatient facility Copayment or Coinsurance. Outpatient Dialysis Services Dialysis Services Copayment or Coinsurance applies at any place of service. Coverage also includes home dialysis equipment and supplies. Outpatient Surgery Outpatient Surgery Copayment or Coinsurance applies to services provided in a freestanding ambulatory surgery center or hospital outpatient surgical facility. Outpatient Lab, Diagnostic, Imaging and Testing Procedures Copayment or Coinsurance will apply when a procedure is done in a free-standing outpatient facility or lab, or a hospital outpatient facility or lab. Outpatient Diagnostic Procedures Diagnostic Procedures X-Ray Ultrasound Doppler Studies Lab Work 2

3 Outpatient Advanced Imaging and Testing Procedures Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Positron Emission Tomography (PET Scans) Computerized Axial Tomography (CT Scans) Computerized Axial Tomography Angiogram (CTA Scans) Magnetic Resonance Spectroscopy (MRS) Single Photon Emission Computed Tomography (SPECT) Nuclear Cardiology Sleep Studies Pre-Authorization is required for all procedures except Sleep Studies, MRS, SPECT and Nuclear Cardiology. 5 Copayment or Coinsurance applies to procedures done in a Physician s office, a free-standing outpatient facility, or a hospital outpatient facility. Maternity Care Maternity Care 7,8,9 Pre-Authorization is required for prenatal services. 5 Includes prenatal, delivery, postpartum services, and home health visits. You must also pay Your inpatient hospital Copayment or Coinsurance. PPACA recommended preventive care services and screenings are covered under the Plan s Preventive Care Benefit. 8 Inpatient Services Inpatient Services Inpatient Hospital Services Transplants are Covered at contracted facilities only. Skilled Nursing Facilities/Services 6 Following inpatient hospital care or in lieu of hospitalization when, in the Plan s judgment, skilled services are required. Services include up to 100 days per stay 6 Ambulance Services Ambulance Services Pre-Authorization is required for non-emergency transportation only. 5 Includes air, water, and ground ambulance for Emergency transportation, or non-emergency transportation that is Medically Necessary and Pre-Authorized by the Plan. Copayment or Coinsurance is applied per transport each way. Emergency Services Emergency Services 2 Pre-Authorization is not required. Includes Emergency Services, Physician services, Advanced Diagnostic Imaging, such as MRIs, and CT scans, and Other Facility Charges, such as diagnostic x-ray and lab services, and medical supplies provided in an emergency department In-Network or Out-of-Network. 3

4 Urgent Care Center Services Urgent Care Center Services Pre-Authorization is not required. Includes Urgent Care Services, Physician services, and other ancillary services received at an Urgent Care facility. If You are transferred to an emergency department from an urgent care center, You will pay an Emergency Services Copayment or Coinsurance. Mental/Behavioral Health & Substance Use Disorder Services Includes inpatient and outpatient services for the treatment of mental health and substance use disorders. Mental/Behavioral Health/Substance Use Disorder Inpatient Services Pre-Authorization is required for all inpatient services. 5 Outpatient Office Visits Pre-Authorization is required for partial hospitalization services, intensive outpatient Program (IOP),transcranial magnetic stimulation (TMS),and electro-convulsive therapy. 5 Employee Assistance Visits 6 Include short-term problem assessment by licensed behavioral health providers, and referral services for employees, and other covered family members and household members. No Copayment for up to 3 visits from Optima Employee Assistance Providers per presenting issue as determined by treatment protocols. 6 DIABETES TREATMENT Coverage includes benefits for equipment, supplies and in-person outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law. Equipment and supplies under this benefit are not considered durable medical equipment. An annual diabetic eye exam is covered from an Optima Health Plan Provider or a participating EyeMed Provider at the applicable office visit Copayment or Coinsurance amount. In-Network Benefits Copayments/%Coinsurance 1,2 Insulin Pumps Pump Infusion Sets and Supplies Testing Supplies Includes test strips, lancets, lancet devices, blood glucose monitors and control solution. Insulin, Needles, and Syringes Outpatient Self-Management Training and Education and Nutritional Therapy Covered under the Plan s Prescription Drug Benefit. Other Covered Services Other Services Prosthetic Devices and Components Services include Medically Necessary Prosthetic devices including repair, fitting, replacement, and components. Component means the materials and equipment needed to ensure the comfort and functioning of a prosthetic device. "Limb" means an arm, a hand, a leg, a foot, or any portion of an arm, a hand, a leg, or a foot. "Prosthetic device" means an artificial device to replace, in whole or in part, a limb. Prosthetic device coverage does not mean or include repair and replacement due to enrollee neglect, misuse, or abuse. Coverage also does not mean or include prosthetic devices designed primarily for an athletic purpose. After Deductible You Pay 30%. 4

5 Other Covered Services Other Services Durable Medical Equipment (DME) and Supplies 6 Orthopedic Devices and Prosthetic Appliances 6 Rehabilitative /Habilitative Devices Pre-Authorization is required for single items over $ Pre-Authorization is required for all rental items. 5 Pre-Authorization is required for repair and replacement. 5 Covered Services include durable medical equipment, orthopedic devices, prosthetic appliances, colostomy, iliostomy, and tracheostomy supplies, and suction and urinary catheters, and repair and replacement; one wig per contract year following cancer treatment. Early Intervention Services Covered for Dependent children from birth to age three who are certified as eligible by the Virginia Department of Behavioral Health and Developmental Services. Covered Services include: Medically Necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices. No therapy visit maximum applies to occupational, physical or speech therapy under this benefit. Home Health Care Skilled Services 6 Services are covered up to a maximum of 100 visits per contract year for home bound Members. 6 Occupational, physical, and speech therapy under this benefit will count toward the home health maximum visit limit. The 100 day home care visit limit does not apply to home dialysis or home infusion therapy. Hospice Care No therapy visit maximum applies to occupational, physical or speech therapy under this benefit. Adult Preventive Vision Exams 6 Optima Health contracts with EyeMed Vision Services to administer this benefit. Coverage includes one examination every 12 months when done by a participating EyeMed Provider. Pediatric Vision Care (Children up to the end of the month the child turns 19) 6 Optima Health contracts with EyeMed Vision Services to administer this benefit. Coverage includes one exam each contract year for glasses or contact lenses, and one pair of glasses, lenses and frames per year from a limited frame collection, or contact lenses from a limited selection instead of glasses. Exams and materials must be received from EyeMed participating providers. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of service. Covered at 100%. For eye examinations from Out-of-Network Providers, Members will be reimbursed up to $30 for an eye examination only. Covered at 100%. 5

6 Other Covered Services Other Services Pediatric Oral Care (Children up to the end of the month the child turns 19) Optima Health contracts with Delta Dental to administer this benefit. Pre-Authorization is required by Delta Dental for all orthodontia services. Services must be received from Delta Dental participating providers. Chiropractic/Osteopathic/Manipulation Therapy 6 Optima Health contracts with American Specialty Health Group (ASH) to administer this benefit. Pre-Authorization is required by ASH for all services. Services include therapy to treat problems of the bones, joints, and back. Maximum number of visits 30 per contract year for Rehabilitative services, and 30 visits per contract year for Habilitative services. Services must be received from ASH participating providers. Reconstructive Breast Surgery For Members who have had a mastectomy, services include surgery and reconstruction, prostheses and physical complications of all stages of mastectomy, including lymphedema. Infertility Services. 6 Includes the following services to diagnose and treat conditions resulting in infertility: Endometrial biopsies (Limited to 2 per lifetime) Semen analysis (Limited to 2 per lifetime) Hysterosalpingography (Limited to 2 per lifetime) Sims-Huhner test (smear) (Limited to 4 per lifetime) Diagnostic laparoscopy (Limited to 1 per lifetime) Excluded are Artificial Insemination (AI), In-Vitro Fertilization (IVF) and all other types of artificial or surgical means of conception and drugs used in connection with these procedures. Services for Interruption of Pregnancy Clinical Trials Coverage includes routine patient costs for Phase I, Phase II, Phase III, or Phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other lifethreatening disease or condition. After Deductible Covered at 100% for: Diagnostic and Preventive Dental Procedures After Deductible You Pay 40% for: Basic Dental Care Simple Restorative Dental Procedures Major Restorative Dental Periodontic Dental Procedures Endodontic Dental Procedures Oral Surgery Dental Procedures Prosthetic/Prosthodontic/Implant Dental Procedures All Other Dental Procedures After Deductible You Pay 50% for: Orthodontic Dental Procedures Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of service. Allergy Care, Testing, and Serum 6

7 Outpatient Prescription Drugs This Plan has a closed formulary and covers a specific list of drugs and medications. If Your drug is not on Our formulary, We have a process in place to request coverage. Please use the following link to see a list of drugs on the Plan s formulary ary.pdf Prescription drugs are placed into tiers. For a single Copayment or Coinsurance charge You may receive up to a consecutive 31-day supply of a covered drug at a retail pharmacy or Optima s Specialty Pharmacy. Under the Mail Order benefit, if Your drug is available, You may receive up to a 90 day supply for the mail order Copayments or Coinsurance amount. Specialty Drugs are not available under the mail order benefit. Copayments/%Coinsurance 1, 2 Retail or Optima Specialty Pharmacy for up to 31 day supply: The entire medical deductible must be met before prescription drug coverage begins. Insulin, syringes, and needles are covered at the cost sharing listed below for the applicable tier. Selected Generic (Tier 1) After Deductible You Pay $10 Copayment. Selected Brand & Other Generic (Tier 2) After Deductible You Pay $40 Copayment. Selected Generic (Tier 1) includes commonly prescribed generic drugs. Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness. Selected Brand & Other Generic (Tier 2) includes brand-name drugs and some generic drugs with higher costs than Tier 1 generics that are considered by the Plan to be standard therapy. Non-Selected Brand (Tier 3) includes brand name drugs not included by the Plan on Tier 1 or Tier 2. These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent. Drugs on this tier may be higher in cost than equivalent drugs, or drugs determined to be no more effective than equivalent drugs on lower tiers. Specialty Drugs (Tier 4) includes those drugs classified by the Plan as Specialty Drugs and compound prescription medications. Specialty Drugs have unique uses and are generally prescribed for people with complex or ongoing medical conditions. Specialty Drugs typically require special dosing, administration, and additional education and support from a health care professional. Specialty Drugs are only available through Optima s specialty mail order pharmacy. Proprium Pharmacy at Specialty drugs will be delivered to your home address from our specialty mail order pharmacy. Specialty Drugs include the following: Medications that treat certain patient populations including those with rare diseases; Medications that require close medical and pharmacy management and monitoring; Medications that require special handling and/or storage; Medications derived from biotechnology and/or blood derived drugs or small molecules; and Medications that can be delivered via injection, infusion, inhalation, or oral administration. Specialty drugs also include drugs subject to restricted distribution by the U.S. Food and Drug Administration. A compound prescription medication is used to meet the needs of a specific individual and must have at least one ingredient requiring a physician s authorization by State or Federal Law. Non-Selected Brand (Tier 3) After Deductible You Pay 40% Coinsurance. Specialty Drugs (Tier 4) After Deductible You Pay 40% Coinsurance, up to a maximum amount of $350 per prescription per 31 day supply. Mail Order (If Your Drug is available) for up to a 90 day supply: Selected Generic (Tier 1) After Deductible You Pay $25 Copayment. Selected Brand & Other Generic (Tier 2) After Deductible You Pay $80 Copayment. Non-Selected Brand (Tier 3) After Deductible You Pay 40% Coinsurance, up to a maximum amount of $400 per prescription per 90 day supply. Specialty Drugs (Tier 4) No 90 day supply mail order benefits are available for Tier 4 drugs. 7

8 Notes All benefits are subject to the terms and conditions in the Evidence of Coverage (EOC). Words that are capitalized are defined terms listed in the Definitions section of the EOC. Children are covered up to the end of the month in which they turn age 26. This Plan does not have pre-existing condition exclusions. This Plan does not have annual or lifetime dollar limits on Your benefits. This is a group plan sponsored by Your employer. Your employer will pay the premium to us on Your behalf. Your employer will tell You how much You must contribute, if any, to the premium. Optima Health has an internal claims appeal process, and an external appeal review process. Please look in Your EOC for details about how to file a complaint or an appeal. Under certain circumstances Your coverage can be terminated. However, Your Coverage can only be Rescinded for fraud or intentional misrepresentation of material fact. Please look in Your EOC in the section on When Your Coverage will end. For Optima Health plans that require that You choose a primary care provider (PCP) You have the right to choose any PCP who participates in Our network and who is available to accept You or Your family members. For children, You may choose a pediatrician as the PCP. 1. You or Your means the Subscriber and each family member who is a Covered Person under the Plan. 2. Copayment and Coinsurance are out-of-pocket amounts You pay directly to a Provider for a Covered Service. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima s Allowable Charge for the Covered Service You receive. Allowable Charge is the amount Optima determines should be paid to a Provider for a Covered Service. When You use In-Network benefits from Plan Providers Allowable Charge is the Provider s contracted rate with Optima or the Provider s actual charge for the service, whichever is less. Plan Providers accept this amount as payment in full. Medically Necessary Covered Services provided by a Non-Plan Provider during an Emergency, or during an authorized Admission to a Plan Facility, will be covered under Your In-Network benefits. All other services You receive from Non-Plan Providers will not be Covered; and You will be responsible for payment of all charges to the Non-Plan Provider. Emergency Care You get Out-of-Network from a Non-Plan Provider will be covered at the In-Network Copayment or Coinsurance level. Cost sharing amounts You pay out of pocket for Out-of-Network Emergency Care will accumulate toward Your Plan s In-Network Deductible and Maximum Out-of-Pocket amounts. 3. Deductible means the dollar amount You and Your family must pay out-of-pocket each contract year for Covered Services before the Plan begins to pay for Your benefits. If You have individual coverage You must satisfy the per individual Deductible before coverage begins. If You have family coverage You and Your family must satisfy the family coverage Deductible. This Plan has an embedded individual Deductible within the family Deductible. That means if one covered family member meets the individual Deductible his or her benefits will begin. Once the total family coverage Deductible is met benefits are available for all covered family members. Deductibles will not be reimbursed under the Plan. The Deductible does not apply to Preventive Care Visits and Screenings. Amounts applied to an In-Network Deductible will apply toward the Plan s In-Network Maximum Out-of-Pocket Limit. Cost sharing amounts You pay for Covered Services that are non-essential Health Benefits will not count toward Your Deductible. 4. Maximum Out-of-Pocket Limit means the total dollar amount You and Your family pay out-of-pocket for most Covered Services during a contract year. Copayments and Coinsurance amounts that You pay for most Covered Services will count toward Your Maximum Out-of-Pocket Limit. Your Deductible will apply toward Your Maximum Out-of-Pocket Limit. If You have individual coverage once You meet the individual Maximum Out-of- Pocket Amount Optima Health will cover most Plan benefits with no out-of-pocket costs for the remainder of Your Plan year. If You have Family coverage and one covered family member meets the individual maximum Optima Health will cover most Plan benefits with no out-of-pocket costs for that family member. Once You and Your family have met the entire family Maximum Out-of-Pocket Amount Optima Health will cover most Covered Services with no out-of-pocket costs for the remainder of Your Plan year for the entire family. However, if a service does not count toward Your Maximum Out-of-Pocket Limit You must continue to pay Your Copayments or Coinsurance for these services after Your Maximum Out-of-Pocket Limit has been met. 8

9 Copayments or Coinsurances or any other charges for the following will not count toward Your Maximum Out-of-Pocket Limit: 1. Amounts You pay for services not covered under Your Plan; 2. Balance billing amounts from Non-Plan Providers; 3. Premium amounts; 4. Amounts You pay as a penalty for failure to comply with the Plan s Pre-Authorization procedures; 5. Cost Sharing amounts including Copayments, Coinsurance, and Deductibles for Covered Services that are not Essential Health Benefits. 5. This benefit requires Pre-Authorization by the provider before You receive services. Your benefits for Covered Services may be reduced or denied if You do not comply with the Plan's Pre-Authorization requirements. 6. Coverage for this benefit or service has a visit, day, hour or other stated limit. The Plan will not cover any additional services after the limits have been reached. You will be responsible for payment for all services after a benefit limit has been reached. Amounts You pay for any services after a benefit limit has been reached are excluded from Coverage and will not count toward Your Maximum Out-of-Pocket Limit. 7. Coverage for obstetrical services as an inpatient in a general Hospital or obstetrical services by a Physician shall provide such benefits with durational limits, Deductibles, Coinsurance factors, and Copayments that are no less favorable than for physical Illness generally. If the Plan charges a Global Copayment for prenatal, delivery, and postpartum services You are entitled to a refund from the Delivering Obstetrician if the total amount of the Global Copayment for prenatal, delivery, and postpartum services is more than the total Copayments You would have paid on a per visit or per procedure basis. 8. Preventive Care includes the services listed below. Services are covered at no cost sharing when received from In-Network Plan Providers. You may be responsible for an office visit Copayment or Coinsurance when You receive preventive care. Some services may be administered under Your prescription drug benefit under the Plan. Please use the following link for a complete list of covered preventive care services: 1. Evidence-based items or services that have in effect a rating of A or B in the recommendations of the U.S. Preventive Services Task Force as of September 23, 2010, with respect to the individual involved; 2. Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. For purposes of this subdivision, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention; 3. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings in the Recommendations for Preventive Pediatric Health by the American Academy of Pediatrics and the Recommended Uniform Screening Panels by the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children; and 4. With respect to women, evidence-informed preventive care and screenings recommended in comprehensive guidelines supported by the Health Resources and Services Administration. Covered Services include the following: Breastfeeding support, supplies, and counseling in conjunction with each birth including: comprehensive lactation support and counseling from trained providers during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment. Contraceptive Methods and Counseling including: Food and Drug Administrationapproved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity. This does not include abortifacient drugs. Screening and Counseling for domestic and interpersonal violence including annual screening and counseling for all women. Gestational diabetes including screening for women between 24 and 28 weeks pregnant, and at the first prenatal visit for pregnant women identified to be at high risk for diabetes. 9

10 Human Immunodeficiency Virus (HIV) including annual screening and counseling for sexually active women. Human Papillomavirus (HPV) DNA Test including: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older. Sexually Transmitted Infections (STI) including annual counseling for sexually active women. Well-woman visits to obtain recommended preventive services for women. Visits will be provided at least annually. Additional visits are covered if needed to obtain all recommended preventive services. 9. You do not need prior authorization from Optima Health or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in Our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, or following a pre-approved treatment plan. Look in Your EOC in the Utilization Management Section for more information on Pre-Authorization. 10

11 Optima Health Alternative Language Options for Notices and other Written Information English: This Notice has Important Information. This notice has important information about your application or coverage through Optima Health. Look for key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call Amharic: ይህ ማስታወቂያ ጠቃሚ መረጃ አለው ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም በOptima Health በኩል ስለሚኖርዎት ሽፋን ጠቃሚ መረጃ አለው በዚህ ማስታወቂያ ላይ ያሉትን ቁልፍ የሆኑ ቀናቶችን ያስተውሉ የጤና ሽፋንዎትን ለማስቀጠል ወይም ወጪዎትን ለማገዝ እንዲቻል በተወሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ሊያስፈልግዎ ይችላል በራስዎ ቋንቋ ያለምንም ክፍያ ይህን መረጃም ሆነ ድጋፍ የማግኘት መብት አለዎት ይደውሉ Arabic: عن ابحث.Optima Health الصحي التا مین شركة لدى بك الخاص التغطیة ببرنامج أو بطلبك تتعلق مھمة معلومات على الا خطار ھذا یحتوي مھمة. معلومات على الا خطار ھذا یحتوي في الحق ولدیك التكالیف. في مساعدة على الحصول أو الصحیة التغطیة برنامج على للحفاظ النھاي یة المواعید حلول قبل إجراء أي اتخاذ إلى تحتاج فقد الا خطار ھذا في الري یسیة التواریخ الاتصال ی رجى تكلفة. أي بدون بلغتك والمساعدة المعلومات ھذه على الحصول Bengali/Bangla: এই ব ত গর প ণর তথয র য় ছ এই প ন Optima Health (অ ম হলথ)-এর ম ধয ম দ খল কর আপন র দরখ ব কভ র জর উপর গর প ণর তথয র য় ছ এই ব ত উ খ কর গর প ণর ত রখগ ল দ খ নন আপন র হলথ কভ রজ বজ য় র খ র জনয ব খর চর বষ য় সহ য়ত ল ভর জনয আপন ক ন দর সময়স ম র ম ধয বয ব হণ কর ত হ ত প র বন খর চ আপন র ম ত ভ ষ য় এই তথয এব সহ য়ত প ওয় র অ ধক র আপন র র য় ছ. কল Chinese (Mandarin): 该通知含有重要信息 本通知含有关于 Optima Health 申请或保险的重要信息 请仔细查看本通知中的关键日期 您需要在截止期之前采取相应的行动, 从而保障您的保险继续有效, 能够为您提供报销 您有权免费获取信息的中文版, 并可以免费获取到相关的中文帮助 請撥電話 French: Cet avis a d'importantes informations. Cet avis a d'importantes informations sur votre demande ou la couverture par l'intermédiaire de Optima Health. Rechercher les dates clés dans le présent avis. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l aide dans votre langue à aucun coût. Appelez German: Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Optima Health. Suchen Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter Hindi: इस स चन म महत वप णर ज नक र न हत ह इस स चन म Optima Health क म ध यम स आपक आव दन य कवर ज क ब र म महत वप णर ज नक र न हत ह इस स चन म न हत महत वप णर त थय क द ख आपक ल गत क स थ अपन स व स थ य क कवर ज रखन य सह यत क लए न त समय स म म क रर व ई करन क ज रत ह सकत ह आपक प स बन कस ल गत क अपन भ ष म इस ज नक र और सह यत क करन क अ धक र ह क ल Ibo: Ọkwa a nwere Ozi Dị Mkpa. Ọkwa a nwere ozi dị mkpa maka akwụkwọ anamachọihe ma ọ bụ mkpuchi gị sitere na Optima Health (Ahụike Optima). Chọọ ụbọchị ndị dị mkpa n'ọkwa a. Ị nwere ike ịme ihe tupu ụfọdụ ụbọchị iji dowe mkpuchi ahụike gị ma ọ bụ enyemaka n'ụgwọ. Ị nwere ike ikike ịnweta ozi na enyemaka a n'asụsụ gị na akwụghị ụgwọ ọ bụla. Kpọ Korean: 이공지는매우중요한정보입니다. 이공지는옵티마핼스를통한귀하께적용되는지원이나보험에대한매우중요한정보입니다. 이공지의주요날짜를찾아보십시오. 귀하께서는귀하의건강보험이나비용에관한도움에관련된특정마감일을지켜야만합니다. 귀하께서는따로비용없이귀하의언어로이정보와도움을받을권리가있습니다. 로전화하십시오 Kru/Bassa: Náùm pò wùɖù nà kɛ kpà ɖɛ mìù. Ɔ mɔ ɖɛ kpà ɖɛ ɓá nì dyí kánà-kánà dyì ɖé Optima Health mú. Mɔ tì kpà ɖɛ ɓè nì ɖé náùm pò wùɖùɔ mú. Mɔ tì kpà ɖɛ ɓè nì ɖé náùm pò wùɖùɔ mú. M ɓè ɖé ɓɛ m ké náùm pò pòɔ ɔ mù pó dyì. Ɔ jù kè m dyì ɖɛ ɓɛà nyùɛn, m wíɖíɔ mù ɓì ɖì dyì. Wà ɓì ɖì ɓɛ wà kè náùm pó wùdù nà kɛ Ɓàsɔ wùɖù mù pò. Sebel

12 Navajo: Díí saad ílíinii baa hane. Naaltsoos ni ííníłtsoozígíí éí doodago kwe é Optima Health nik é ésti ígíí bína ídíłkidgo díí kwe é hazhó ó baa ákonínízin dooleeł. Yoołkááł yę ędą ą nich į é élyaago biká ígíí hádídíí įįł. Díí niké ésti ígíí éi doodago béeso da bee níká a doowołígíí bikáa go da át ée dooleeł áko t áadoo bee e e aahí baa yíłkaahgo tsxį į łgo hasht e díílííł níi da dooleeł. Bee haz áanii hólǫ díí kót éego yaa halne ígíí bee níká a doowołgo dóó t áá nizaadk ehjí bee nił hodoonih t áadoo bą ą h ílíní. Átah ánǫ t í ígíí bee baa áháyą ągéé bich į bibéésh bee hane í hwéédilní Persian/Farsi: این اعلامیھ حاوی اطلاعات مھمی است. این اعلامیھ حاوی اطلاعات مھمی درباره درخواست شما و پوشش Optima Health است. بھ تاریخ ھای کلیدی عنوان شده در این اعلامیھ دقت کنید. ممکن است لازم باشد تا یک تاریخ مقرر خاص اقدام کنید تا پوشش بیمھ تان حفظ شود یا در رابطھ با ھزینھ ھا بھ شما کمک شود. شما از این حق برخوردار ھستید تا این اطلاعات و ھرگونھ راھنمایی دیگر را بھ زبان خودتان و بھ صورت رایگان دریافت کنید Russian: В данном уведомлении содержится важная информация. В данном уведомлении содержится важная информация о Вашей заявке или страховом покрытии в компании Optima Health. Обратите внимание на важные дaты, указанные в данном уведомлении. Если Вы хотите продолжать пользоваться мед.страхованием или получить помощь с оплатой, возможно, Вам потребуется принять решение до определенной даты. У Вас есть право на бесплатное получение данной информации и помощи на родном языке. Звоните по телефону Spanish: Este Aviso contiene información importante. Este aviso contiene información importante acerca de su solicitud o cobertura a través de Optima Health. Preste atención a las fechas clave que contiene este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al Tagalog: Ang Paunawang Ito ay Naglalaman ng Mahalagang Impormasyon. Ang paunawang ito ay naglalaman ng mahalagang impormasyon tungkol sa inyong aplikasyon o saklaw sa pamamagitan ng Optima Health. Hanapin ang mahahalagang petsa na nakasaad sa paunawang ito. Maaaring kailanganin ninyong gumawa ng hakbang bago sumapit ang ilang partikular na takdang petsa upang mapanatili ang inyong saklaw na pangkalusugan o tulong sa mga gastusin. Mayroon kayong karapatan na matanggap ang impormasyong ito at makakuha ng tulong sa inyong wika nang walang bayad. Tumawag sa Urdu: اس نوڻس میں اہم اطلاع موجود ہے اس نوڻس میں آپ کی درخواست یا Optima Health کے ذریعے کوریج کے حوالے سے اہم اطلاع موجود ہے اس نوڻس میں درج کلیدی تاریخوں کو ذہن میں رکھیں آپ کے لیے ضروری ہے کہ مخصوص ڈیڈلاي نوں سے قبل اس حوالے سے کوي ی ایکشن لیں تاکہ آپ کی کوریج براي ے صحت اور لاگت کے حوالے سے معاملات طے رہیں آپ اس اطلاع تک رساي ی اور بغیر کسی خرچ کے اپنی زبان میں اس بابت جاننے Vietnamese: Thông báo này có thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn đăng ký hoặc về bảo hiểm của quý vị thông qua Optima Health. Quý vị hãy xem những ngày quan trọng trong thông báo này. Quý vị có thể cần đưa ra hành động trước ngày hết hạn cụ thể để duy trì bảo hiểm sức khỏe của quý vị hoặc hỗ trợ thanh toán cho các chi phí. Quý vị có quyền nhận được thông tin và sự hỗ trợ này theo ngôn ngữ mà quý vị muốn mà không phải trả thêm chi phí nào. Xin gọi số Yoruba: Àkíyèsí yìí ní Àlàyé Pàtàkì. Àkíyèsí yìí ní àlàyé pàtàkì nípa ohun tí o bèèrè fún tàbí gbígbà ìtọ jú nípasẹ Optima Health. Wo àwọn ọjọ tó ṣe kókó nínú àkíyèsí yìí. O lè nílò láti gbé ìgbésẹ nípa gbèdéke kan láti ṣètọ jú ìlera rẹ tàbí ṣèrànw ọ nípa iye òwó. O ní ẹ tọ láti gba àlàyé yìí àti ìrànwọ yìí ní èdè rẹ láìsan owó. Pè sórí