Navigator by Tufts Health Plan Benefit Summary. Effective January 1, 2014 STATE STREET

Navigator by Tufts Health Plan Benefit Summary Effective January 1, 2014 STATE STREET

BENEFIT SUMMARY With Tufts HMO Navigator TM by Tufts Health Plan, you enjoy quality coverage for your health care needs. Preventive and medically needed health care services and supplies are, for the most part, covered when they are given by providers in the Tufts Health Plan network. Please note: throughout this summary, the Tufts HMO Navigator plan will be referred to as Navigator. As a Navigator plan member: You don t need referrals. In most cases, you must get care from a network provider. You can choose to pay lower inpatient hospital copays by choosing network hospitals with a best quality and costefficiency rating. You can choose between two copay levels for provider office visits, depending on the type of provider you see PCP or specialist. We suggest that plan members work closely with their provider to coordinate their health care needs. You do not need referrals for visits with specialists. Please include your PCP s information when you sign up for your health plan. Preventive Services Office visit copays for network providers depend on the type of provider you see. Network PCPs, PCPs who are also specialists, pediatricians, and OB/GYNs Covered at $25 for each office visit Network specialists Covered at $45 for each office visit Care at network hospitals is covered at three copay levels for obstetric care, pediatric care, and adult medical/surgical care: Copay Level 1: Hospitals with a best quality and costefficiency rating after a $250 copay for each admission Copay Level 2: Hospitals with a better quality and costefficiency rating after a $500 copay for each admission Copay Level 3: Hospitals with a good quality and costefficiency rating after a $750 copay for each admission Please look over the Navigator Inpatient Hospital Copayment List in this brochure. To find providers and hospitals in the Tufts Health Plan network, visit tuftshealthplan.com/statestreet or call a member specialist. Routine Physical Exams (including well-child care visits, annual gynecological exams, and most preventive screenings) Screening for Colon or Colorectal Cancer in the Absence of Symptoms Outpatient Medical Care Non-routine Primary Care Physician Office Visits and Urgent Care Non-routine Specialist Office Visits and Urgent Care Outpatient Maternity Care (This office visit copay will apply to the first visit only.) Routine Eye Exams With an EyeMed Vision Care provider (one visit per calendar year) Immunizations Preventive Pap Smears and Mammograms Allergy Injections Nutritional Counseling (when medically necessary) Speech Therapy Short-Term Physical and Occupational Therapy (up to 60 consecutive days for each type of service per calendar year) Colonoscopy Generally Associated with Symptoms (Including Family History of Cancer) without surgical intervention Colonoscopy Generally Associated with Symptoms (Including Family History of Cancer) with surgical intervention Diagnostic Lab Tests and Diagnostic Imaging (such as X-rays, ultrasounds, diagnostic pap smears and mammograms) Diagnostic Imaging High-Tech Imaging (such as MRIs, CT/CAT scans, PET scans, and nuclear cardiology) (copay is limited to 5 per member per calendar year; limit one copay per member per calendar year for cancerrelated diagnosis. The one copay limit is counted toward the member s 5 per member per calendar year limit) Day Surgery (office visit copay applies in office setting; copay is limited to 2 per member per calendar year) $45 per visit $200 per visit $200 per image $200 per admission

Inpatient Hospital Care and Surgery (semiprivate room, unless private room is medically necessary) All Hospital Services Acute Care, Maternity Care and Pediatric (copay is limited to 2 per member per calendar year) Skilled Nursing in Skilled Nursing Facility (up to 100 days per plan year) Emergency Care Primary Care Physician $250 - Copay Level 1 $500 - Copay Level 2 $750 - Copay Level 3 Specialist In Provider s Office $45 per visit In Emergency Room (copay waived if admitted) Mental Health and Substance Abuse Outpatient Care Inpatient Care (copay is limited to 2 per member per calendar year) Other Health Services $150 per visit $250 per admission Durable Medical Equipment Plan pays 80%, Member pays 20% Ambulance Service Hospice Care Home Health Care Great Savings While You Get Healthy In addition to your covered benefits, we offer great savings on a wide variety of healthy products, services, and treatments. You save while you re taking care of your health. That s a real win-win. To learn more, visit tuftshealthplan.com and click on Discounts on the I m a Member tab. There are some services that the plan does not cover. These include, but are not limited to: A service or supply not described as a covered service in your Tufts Health Plan member benefit document Exams required by a third party, such as your employer, an insurance company, a school, or court Cosmetic surgery or any other cosmetic procedure, except certain reconstructive procedures described in your Tufts Health Plan member benefit document Experimental or investigational drugs, services, and procedures Eyeglasses or contact lenses, except as described in your Tufts Health Plan member benefit document Blood, blood donor fees, blood storage fees, blood substitutes, blood banking, cord blood banking, or blood products, except as described in your Tufts Health Plan member benefit document Drugs for use outside of a hospital, except as covered under a separate plan through Express Scripts Personal comfort items Custodial care A service furnished to someone other than the member Routine foot care, except as described in your Tufts Health Plan member benefit document Charges incurred for stays in a covered facility beyond the discharge hour Care for conditions that state or local law requires be treated in a public facility Medical or surgical procedures for reversal of voluntary sterilization Foot orthotics, except therapeutic/molded shoes for an individual with severe diabetic foot disease Spinal manipulation services Private-duty nursing (block or nonintermittent nursing) Hearing aids Except for emergency care or urgent care while traveling, a service, supply or medication that is obtained outside of the 50 United States This is a summary only. Please refer to the member benefit document for a detailed explanation of your coverage. If there is a difference between the information in this benefit summary and your member benefit document, the terms of your member benefit document will govern. If you have additional questions, please call a Member Specialist at 800-462-0224. Administered by Tufts Benefit Administrators, Inc., a Tufts Health Plan company. Massachusetts Requirement to Purchase Health Insurance: As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MA-ENROLL or visit the Connector website (www.mahealthconnector.org).

Navigator Copayments For Inpatient Hospital Admissions Lower copays in the chart below identify hospitals that meet Tufts Health Plan s standards for an excellent quality and cost-efficiency rating. OBSTETRIC CARE PEDIATRIC CARE ADULT MEDICAL/ REGION HOSPITAL COPAYMENT COPAYMENT SURGICAL COPAYMENT MASSACHUSETTS East Anna Jaques Hospital $250 $500 (NL*) $250 Beth Israel Deaconess Hospital - Milton $500 (NL*) $500 (NL*) $250 Beth Israel Deaconess Medical Center - Needham $500 (NL*) $500 (NL*) $500 Beth Israel Deaconess Medical Center $750 $500 (NL*) $500 Boston Medical Center $250 $250 $250 Brigham and Women s Hospital $750 $500 (NL*) $750 Brockton Hospital $250 $250 $250 Cambridge Hospital (Part of Cambridge Health Alliance) $250 $500 (NL*) $500 Cape Cod Hospital $250 $250 $250 Carney Hospital $500 (NL*) $500 (NL*) $250 Charlton Memorial Hospital $750 $500 (NL*) $750 Children s Hospital $500 (NL*) $500 $500 (NL*) Dana-Farber Cancer Institute $500 (NL*) $500 (NL*) $500 (NL*) Emerson Hospital $500 $250 $500 Falmouth Hospital $250 $250 $250 Faulkner Hospital $500 (NL*) $500 (NL*) $250 Good Samaritan Medical Center $250 $500 (NL*) $500 Hallmark Health System - (Lawrence Memorial or Melrose Wakefield hospitals) $250 $500 (NL*) $500 Holy Family Hospital $250 $250 $250 Jordan Hospital $250 $250 $250 Lahey Clinic Hospital $500 (NL*) $500 (NL*) $500 Lawrence General Hospital $250 $250 $250 Lowell General Hospital $250 $250 $250 Martha s Vineyard Hospital $750 $500 (NL*) $750 Massachusetts Eye and Ear Infirmary $500 (NL*) $500 (NL*) $500 (NL*) Massachusetts General Hospital $750 $500 $750 Merrimack Valley Hospital $500 (NL*) $500 (NL*) $500 Metrowest Medical Center $250 $250 $250 Morton Hospital and Medical Center $250 $250 $500 Mount Auburn Hospital $250 $500 (NL*) $250 Nantucket Cottage Hospital $750 $500 (NL*) $250 New England Baptist Hospital $500 (NL*) $500 (NL*) $500 (NL*) Newton-Wellesley Hospital $500 $250 $250 North Shore Medical Center - (Salem or Union campuses) $500 $250 $500 Northeast Hospital Corporation (Addison Gilbert or Beverly hospitals) $250 $250 $250 Norwood Hospital $250 $250 $250 Quincy Medical Center $500 (NL*) $500 (NL*) $500 Saints Memorial Medical Center $500 (NL*) $500 (NL*) $250 South Shore Hospital $250 $250 $250 St. Anne s Hospital $500 (NL*) $250 $500 St. Elizabeth s Medical Center $250 $500 (NL*) $250 St. Luke s Hospital $750 $500 $750 Sturdy Memorial Hospital $250 $500 (NL*) $250 Tobey Hospital $750 $500 (NL*) $750 Tufts Medical Center $500 $250 $250 Winchester Hospital $250 $250 $500 NL* These hospitals are not grouped in a copayment/coinsurance level because they: (1) are a specialized hospital, (2) have fewer than 100 admissions per year for pediatrics or obstetrics, (3) do not provide pediatric or obstetric services, or (4) are a network hospital outside of Massachusetts. Members are encouraged to contact their treating provider or the hospital directly if they have questions about the services available at a specific hospital. Please note that the status and copayment levels of our network of providers are effective as of January 1, 2014. For the most up-to-date status, please contact Member Services at 800-462-0224, or visit tuftshealthplan.com/statestreet. OBSTETRIC SERVICES These services include the inpatient care and treatment for any pregnancy-related condition, once a diagnosis of pregnancy has been confirmed. For example: childbirth, preterm labor, toxemia, and newborn care while mother and baby are in the hospital. PEDIATRIC SERVICES These services include the inpatient care and treatment of members under age 18 for a medical or surgical condition. NOTE: All adult and pediatric transplants are covered with a $250 copayment when authorized at a Transplant Center of Excellence. ADULT MEDICAL AND SURGICAL SERVICES These services include the inpatient care and treatment of members, age 18 and older, for a medical or surgical condition. For example: gynecology, gastroenterology, cardiology, and orthopedics. 4

Lower copayments in the chart below identify hospitals that meet Tufts Health Plan s standards for an excellent quality and cost-efficiency rating. OBSTETRIC CARE PEDIATRIC CARE ADULT MEDICAL/ REGION HOSPITAL COPAYMENT COPAYMENT SURGICAL COPAYMENT Central Athol Memorial Hospital $500 (NL*) $500 (NL*) $500 Clinton Hospital $500 (NL*) $500 (NL*) $500 Harrington Memorial Hospital $250 $250 $500 HealthAlliance Hospitals $750 $500 $750 Henry Heywood Hospital $250 $250 $500 Marlborough Hospital $500 (NL*) $500 (NL*) $750 Milford Regional Medical Center $500 $500 (NL*) $250 Nashoba Valley Medical Center $500 (NL*) $500 (NL*) $500 St. Vincent Hospital $500 $250 $500 UMASS Memorial Medical Center $750 $500 $750 West Baystate Medical Center $500 $250 $250 Berkshire Medical Center $250 $250 $250 Cooley Dickinson Hospital $250 $250 $250 Fairview Hospital $250 $500 (NL*) $250 Franklin Medical Center $250 $500 (NL*) $500 Holyoke Hospital $250 $500 (NL*) $500 Mary Lane Hospital $500 (NL*) $500 (NL*) $250 Mercy Medical Center $250 $500 (NL*) $500 Noble Hospital $500 (NL*) $500 (NL*) $250 North Adams Regional Hospital $500 $500 (NL*) $500 Wing Memorial Hospital and Medical Center $500 (NL*) $500 (NL*) $250 NEW HAMPSHIRE RHODE ISLAND Catholic Medical Center $500 (NL*) $500 (NL*) $500 (NL*) Elliot Hospital $500 (NL*) $500 (NL*) $500 (NL*) Exeter Hospital $500 (NL*) $500 (NL*) $500 (NL*) Mary Hitchcock Memorial Hospital $500 (NL*) $500 (NL*) $500 (NL*) Parkland Medical Center $500 (NL*) $500 (NL*) $500 (NL*) Portsmouth Regional Hospital $500 (NL*) $500 (NL*) $500 (NL*) Southern N.H. Regional Medical Center $500 (NL*) $500 (NL*) $500 (NL*) St. Joseph Hospital $500 (NL*) $500 (NL*) $500 (NL*) Kent County Hospital $500 (NL*) $500 (NL*) $500 (NL*) Landmark Medical Center $500 (NL*) $500 (NL*) $500 (NL*) Memorial Hospital of R.I. $500 (NL*) $500 (NL*) $500 (NL*) Miriam Hospital $500 (NL*) $500 (NL*) $500 (NL*) Newport Hospital $500 (NL*) $500 (NL*) $500 (NL*) Rhode Island Hospital - including Hasbro Children s Hospital $500 (NL*) $500 (NL*) $500 (NL*) Roger Williams Medical Center $500 (NL*) $500 (NL*) $500 (NL*) South County Hospital $500 (NL*) $500 (NL*) $500 (NL*) St. Joseph s Hospital - including Fatima Hospital $500 (NL*) $500 (NL*) $500 (NL*) The Westerly Hospital $500 (NL*) $500 (NL*) $500 (NL*) Women and Infants Hospital $500 (NL*) $500 (NL*) $500 (NL*) VERMONT Southwestern Vermont Medical Center $500 (NL*) $500 (NL*) $500 (NL*) NL* These hospitals are not grouped in a copayment/coinsurance level because they: (1) are a specialized hospital, (2) have fewer than 100 admissions per year for pediatrics or obstetrics, (3) do not provide pediatric or obstetric services, or (4) are a network hospital outside of Massachusetts. Members are encouraged to contact their treating provider or the hospital directly if they have questions about the services available at a specific hospital. Please note that the status and copayment levels of our network of providers are effective as of January 1, 2014. For the most up-to-date status, please contact Member Services at 800-462-0224, or visit tuftshealthplan.com/statestreet. Tufts Health Plan used the methodology described at tuftshealthplan.com to develop the Navigator Inpatient Hospital List. This hospital list and the - Value Index are two tools among many to help you and your physician determine the most appropriate place for you to receive your care. OBSTETRIC SERVICES These services include the inpatient care and treatment for any pregnancy-related condition, once a diagnosis of pregnancy has been confirmed. For example: childbirth, preterm labor, toxemia, and newborn care while mother and baby are in the hospital. PEDIATRIC SERVICES These services include the inpatient care and treatment of members under age 18 for a medical or surgical condition. NOTE: All adult and pediatric transplants are covered with a $250 copayment when authorized at a Transplant Center of Excellence. ADULT MEDICAL AND SURGICAL SERVICES These services include the inpatient care and treatment of members, age 18 and older, for a medical or surgical condition. For example: gynecology, gastroenterology, cardiology, and orthopedics. 5

- Value Index This - Value Index offers more specific information which Tufts Health Plan used in determining whether a hospital was grouped in Tier 1, Tier 2, or Tier 3 on the Navigator Inpatient Hospital List. The index illustrates each hospital s quality score and its cost score, giving you more information to make decisions about where to seek care. Individual hospital information is based on a quartile system. For example, a hospital with a quality score in the top 25 percent will receive four stars, and conversely, a hospital with a quality score in the bottom 25 percent will receive one star. Hospital Obstetrics Pediatrics Adult Med/Surg n/a = refers to hospitals that have less than 100 admissions in a given specialty and, therefore, were not rated COST QUALITY Q1 $ 25th percentile or less (least costly) Q1 HHHH 76th percentile or more (highest quality) Q2 $$ 26th - 50th percentile Q2 HHH 51st - 75th percentile Q3 $$$ 51st - 75th percentile Q3 HH 26th - 50th percentile Q4 $$$$ 76th percentile or more (most costly) Q4 H 25th percentile or less (lowest quality) KEY Anna Jaques Hospital $ HH n/a n/a $ HHH Athol Memorial Hospital n/a n/a n/a n/a $$ H Baystate Medical Center $$$$ HHHH $$ HHHH $$$ HHH Berkshire Medical Center $$$ HHH $$$ HHH $$$$ HHHH Beth Israel Deaconess Hospital-Milton n/a n/a n/a n/a $ HHH Beth Israel Deaconess Medical Center - Needham n/a n/a n/a n/a $$ H Beth Israel Deaconess Medical Center $$$$ HHH n/a n/a $$$$ HHHH Boston Medical Center $$ HHHH $ HHHH $ HHH Brigham and Women s Hospital $$$$ HHHH n/a n/a $$$$ HHHH Brockton Hospital $ HHH $ HHH $ HHH Cambridge Hospital (Part of Cambridge Health Alliance) $ HHHH n/a n/a $$ HH Cape Cod Hospital $ HHH $$$ HHH $$ HHHH Carney Hospital n/a n/a n/a n/a $$ HHH Charlton Memorial Hospital $ H n/a n/a $$$$ H Children s Hospital n/a n/a $$$$ HHHH n/a n/a Clinton Hospital n/a n/a n/a n/a $$$ HHH Cooley Dickinson Hospital $ HHH $$ HHH $$$ HHHH Emerson Hospital $$$$ HHH $$$$ HHH $$ HHH Fairview Hospital $$$$ HHH n/a n/a $$$$ HHHH Falmouth Hospital $ HHH $$$ HH $$$ HHH Faulkner Hospital n/a n/a n/a n/a $$$ HHHH Franklin Medical Center $$$ HHH n/a n/a $$ H Good Samaritan Medical Center $$ HHHH n/a n/a $$ HH Hallmark Health System - (Lawrence Memorial or Melrose Wakefield hospitals) $$$ HHHH n/a n/a $$ HHH Harrington Memorial Hospital $ HH $$ HH $ H HealthAlliance Hospitals $$ H $$$ H $$ H Henry Heywood Hospital $ HH $ HH $ H Holy Family Hospital $$$ HHH $$ HHH $ HHHH Holyoke Hospital $ HHHH n/a n/a $$ H Jordan Hospital $ HHH $$$ HHH $ HH 6

Hospital Obstetrics Pediatrics Adult Med/Surg n/a = refers to hospitals that have less than 100 admissions in a given specialty and, therefore, were not rated Tufts Health Plan used the methodology described at tuftshealthplan.com/statestreet to develop the Navigator Inpatient Hospital List. The hospital list and the - Value Index are two tools among many to help you and your physician determine the most appropriate place for you to receive your care. COST QUALITY Q1 $ 25th percentile or less (least costly) Q1 HHHH 76th percentile or more (highest quality) Q2 $$ 26th - 50th percentile Q2 HHH 51st - 75th percentile Q3 $$$ 51st - 75th percentile Q3 HH 26th - 50th percentile Q4 $$$$ 76th percentile or more (most costly) Q4 H 25th percentile or less (lowest quality) KEY Lahey Clinic Hospital n/a n/a n/a n/a $$$$ HHH Lawrence General Hospital $$ HH $ HH $ HH Lowell General Hospital $$ HH $ HH $ HH Marlborough Hospital n/a n/a n/a n/a $$ H Martha s Vineyard Hospital $$$$ H n/a n/a $$$$ HH Mary Lane Hospital n/a n/a n/a n/a $$ HHH Massachusetts General Hospital $$$$ HHHH $$$$ HHHH $$$$ HHHH Mercy Hospital $ H n/a n/a $ H Merrimack Valley Hospital n/a n/a n/a n/a $$ H Metrowest Medical Center $$ HHH $$$ HH $$ HHH Milford Regional Medical Center $$ HH n/a n/a $$$ HHHH Morton Hospital and Medical Center $ HHH $ HHH $ H Mount Auburn Hospital $$$ HHHH n/a n/a $$$ HHHH Nantucket Cottage Hospital $$$ H n/a n/a $$$ HHHH Nashoba Valley Medical Center n/a n/a n/a n/a $$ H Newton-Wellesley Hospital $$$$ HHHH $$$ HHHH $$ HHHH Noble Hospital n/a n/a n/a n/a $ HHH North Adams Regional Hospital $$$$ HH n/a n/a $$$$ HHH North Shore Medical Center - (Salem or Union campuses) $$$$ HHHH $$$$ HHHH $$$$ HHHH Northeast Hospital Corporation (Addison Gilbert or Beverly hospitals) $$$ HHH $$ HHH $$ HHHH Norwood Hospital $$ HHHH $$ HHHH $ HHH Quincy Medical Center n/a n/a n/a n/a $$ H Saints Memorial Medical Center n/a n/a n/a n/a $ HH South Shore Hospital $$$ HHH $$$ HHH $$ HHH St. Anne s Hospital n/a n/a $$$ HHH $$ HHH St. Elizabeth s Medical Center $$$$ HHHH n/a n/a $$ HHHH St. Luke s Hospital $ H $$$ H $$$$ H St. Vincent Hospital $$$ HH $$$ HH $$$ HHH Sturdy Memorial Hospital $ HHH n/a n/a $$$ HHHH Tobey Hospital $ H n/a n/a $$$ H Tufts Medical Center $$$ HHH $$ HH $ HHH UMASS Memorial Medical Center $$$ H $$ H $$$$ H Winchester Hospital $ HHH $$$ HHH $$$ HHH Wing Memorial Hospital and Medical Center n/a n/a n/a n/a $$ HHH 7

Administered by Tufts Benefit Administrators, Inc., a Tufts Health Plan company 705 Mount Auburn Street Watertown, MA 02472 Member Services 800-462-0224 tuftshealthplan.com/statestreet 18540_11/13