Common use of Active Employees Clause in Contracts

Active Employees. Our goal...to educate all employees so they can make an informed healthcare decision. Benefit BlueChoice (HMO) “Open Access” Plan BlueChoice (HMO) Low Option “Open Access” Plan Acupuncture Services $10 co-pay, 24 visits per calendar year Not covered (except when approved or authorized by plan when used for anesthesia) Chiropractic Services $10 co-pay, 20 visits per calendar year Office Setting – Deductible, then $40/visit; 20 visits per calendar year Dental Services as a result of an accidental injury $10 co-pay – Covered for accidental bodily injury or to correct congenital anomalies 100% Allowed Benefit after deductible Diagnostic, Lab Services, X-ray Covered in full for x-rays and lab services (Lab Corp only) Other diagnostic – $10 co-pay (eg., MRIs) Non-routine, office setting; $40 co-pay/visit Durable Medical Equipment 100% Allowed Benefit 50% Allowed Benefit after deductible Emergency Room Visits Medical Emergency – $50 co-pay, waived if admitted Urgent Care Centers – $10 co-pay $300 co-pay after deductible (waived if admitted) Urgent Care Centers – $100 co-pay after deductible Family Planning/Fertility (subject to state mandate) Infertility Counseling & Testing – $10 co-pay Artificial Insemination – covered at 50% of the plan allowance; IVF – covered at 50% of the plan allowance (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) 50% Allowed Benefit after deductible; IVF – (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam – no co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Covered for minor children (up to age 18). 100% Allowed Benefit for each ear (co-pays and deductible do not apply); member may be balance billed up to total charge. Hospitalization (Inpatient)/ Surgery Covered in full 30% Allowed Benefit after deductible Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. 30% Allowed Benefit after deductible Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $5 co-pay per visit. Office Setting – $30 co-pay after deductible Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for pre- and postnatal services. Delivery and hospitalization – 30% Allowed Benefit after deductible Outpatient Surgery $5 co-pay PCP; $10 co-pay specialist Office Setting – $30 PCP co-pay/$40 Specialist co-pay Physical Therapy $10 co-pay; 30 visits/per condition/per calendar year. PCP referral required. Office Setting – $40 co-pay; limited to 30 days/condition/ benefit period; combined with speech & occupational therapy Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 preferred brand/$25 non-preferred brand MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 preferred brand/$50 non-preferred brand Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE: $150 RETAIL: $500 deductible, then: $15 generic/$35 preferred brand/$60 non-preferred brand; self-injectables – 50% coinsurance up to a max payment of $150 (30 days) MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $30 generic/$70 preferred brand/$120 non-preferred brand; self-injectables – 50% coinsurance up to a max payment of $300 (90 days) Routine Physicals No co-pay No co-pay Vision Care $10 co-pay through Xxxxx Vision Providers – Optometrists or Opthamologists. Limited to one examination per calendar year. Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. $10 co-pay through Xxxxx Vision Providers. Routine eye exam (limited to 1 visit/per year). Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. Well Child Care No co-pay No co-pay Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health Primary Care Office Visit Co-pays/ Specialist Office Visit Co-pays $5 co-pay $10 co-pay $30 co-pay after deductible $40 co-pay after deductible Calendar Year Deductible N/A Individual – $4,500 individual; family – $9,000 Co-insurance 100% Plan pays 70%; employee pays 30% Out-of-Pocket Maximum (Medical Only) Individual – $2,000; family – $6,000 Individual – $6,350; family – $12,700 Out-of-Pocket Max. (Comb. Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Calendar Year Maximum Unlimited Unlimited Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services Dependents must be added within 31 days of becoming eligible or wait until the next open enrollment period. • Dependents are covered until end of BlueChoice Triple Option “Open Access” Plan Xxxxx 0 Xxxxx 0 Xxxxx 0 $10 co-pay, 24 visits per calendar year $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 20 visits per year) $15 co-pay (unlimited visits) 80% Allowed Benefit after deductible (unlimited visits) $10 co-pay covered for accidental bodily injury or to correct congenital anomalies 90% Allowed Benefit after deductible covered for accidental bodily injury or to correct congenital anomalies 80% Allowed Benefit after deductible Lab no co-pay (Lab Corp only) Other diagnostic – $10 co-pay (eg., MRIs). $15 co-pay 80% Allowed Benefit after deductible 100% Allowed Benefit 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible $50 co-pay (waived if admitted) Urgent Care Centers – $10 co-pay Considered under Level 1. If Benefits are not available under Xxxxx 0, benefits may be payable under the appropriate level. Urgent Care Centers – $15 co-pay 80% Allowed Benefit after deductible Processed under Xxxxx 0 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Hearing exam – no co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Hearing exam – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. No co-pay 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. No co-pay 100% Allowed Benefit, no deductible 80% Allowed Benefit after deductible No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $10 co-pay per visit $10 co-pay per visit Deductible and co-insurance apply No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for prenatal services. Hospitalization covered at 90% of Allowed Benefit after deductible. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. $10 co-pay $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 30 visits/per condition/per year) $15 co-pay (limited to 100 visits per year) 80% Allowed Benefit after deductible (limited to 100 visits per year) RETAIL: $5 generic/$15 preferred brand/$25 non-preferred brand MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 preferred brand/$50 non-preferred brand Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE: $150 No co-pay No co-pay 80% Allowed Benefit, no deductible $10 co-pay at Plan-designated Vision Care Centers (Xxxxx Vision Providers). Discounts on glasses and contact lenses from Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. Not Covered — refer to Level 1 benefits or the CareFirst Select Vision plan. No co-pay No co-pay 80% Allowed Benefit, no deductible Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health $10 co-pay $10 co-pay $15 co-pay $15 co-pay 80% Allowed Benefit, after deductible Individual/family – $0 Individual – $200; family – $400 Individual – $300; family – $600 100% 90% 80% Individual – $2,000; family – $6,000 Individual – $500; family – $1,000 Individual – $1,000; family – $2,000 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Unlimited Unlimited Unlimited Unlimited, except for fertility services Unlimited, except for fertility services Unlimited, except for fertility services the month in which they turn 26. • This chart is for comparison purposes only. Please consult each plan benefit summary (available on-line) for full details. Benefit CareFirst/BCBS Preferred ProviderNetwork (PPN) In-Network Out-of-Network Acupuncture Services Only covered with certain diagnosis. Contact BCBS to verify. $15 co-pay for preferred provider. Only covered with certain diagnosis. Contact BCBS to verify. 80% of Allowed Benefit, after deductible. Chiropractic Services $15 co-pay in-network Benefit paid at 80% of Allowed Benefit after deductible Dental Services as a result of an accidental injury Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Diagnostic, Lab Services, X-ray 100% of Allowed Benefit 80% of Allowed Benefit after deductible Durable Medical Equipment 100% of Allowed Benefit 80% of Allowed Benefit after deductible Emergency Room Visits $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay Family Planning/Fertility (subject to state mandate) Plan of treatment required Artificial Insemination – 100% of allowed mandate, some services may require co-pay; IVF – 100% of Allowed Benefit, some services may require co-pay (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Plan of treatment required Artificial Insemination – 80% of allowed benefit after deductible; IVF – 80% of Allowed Benefit after deductible (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear. Hospitalization (Inpatient)/ Surgery 100% up to 365 days 80% after deductible/365 days Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $15 co-pay per visit No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. Deductible and co-insurance applies. Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. Outpatient Surgery 100% of Allowed Benefit 80% of Allowed Benefit after deductible Physical Therapy 100 visits per year with $15 co-pay per office visit Deductible, then 80% of Allowed Benefit for 100 visits per calendar year Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 preferred brand/$25 non-preferred brand MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 preferred brand/$50 non-preferred brand Units 5 & 6—4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE: $150 Routine Physicals No co-pay 80% of Allowed Benefit, after deductible Vision Care Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Well Child Care No co-pay 80% of Allowed Benefit, after deductible Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 Magellan Behavioral Health Primary Care Office Visit Co-pays/ Specialist Office Visits Co-pays 100% of Allowed Benefit after $15 100% of Allowed Benefit after $15 80/20 after deductible Calendar Year Deductible N/A Individual – $200; family – $400 Co-insurance 100% 80/20 Out-of-Pocket Max. (Medical Only) Individual – $1,200; family – $2,400 Individual – $1,200; family – $2,400 Out-of-Pocket Max. (Combined Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700

Active Employees. Our goal...to educate all employees so they can make an informed healthcare decision. Benefit BlueChoice (HMO) “Open Access” Plan BlueChoice (HMO) Low Option “Open Access” Plan Acupuncture Services $10 15 co-pay, 24 visits per calendar year Not covered (except when approved or authorized by plan when used for anesthesia) Chiropractic Services $10 15 co-pay, 20 visits per calendar year Office Setting – Deductible, then $40/visit; 20 visits per calendar year Dental Services as a result of an accidental injury $10 No co-pay – Covered for accidental bodily injury or to correct congenital anomalies 100% Allowed Benefit after deductible Diagnostic, Lab Services, X-ray Covered in full for x-rays and lab services (Lab Corp only) Other diagnostic – $10 15 co-pay (eg., MRIs) Non-routine, office setting; $40 co-pay/visit (Lab Corp only for lab services) Durable Medical Equipment 100% Allowed Benefit 50% Allowed Benefit after deductible Emergency Room Visits Medical Emergency – $50 65 co-pay, waived if admitted Urgent Care Centers – $10 PCP co-pay/$15 Specialist co-pay $300 co-pay after deductible (waived if admitted) Urgent Care Centers – $100 co-pay after deductible Family Planning/Fertility (subject to state mandate) Infertility Counseling & Testing – $10 co-pay Artificial Insemination – covered at 50% of the plan allowance; IVF – covered at 50% of the plan allowance (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) 50% Allowed Benefit after deductible; IVF – (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam – no $10 co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Covered for minor children (up to age 18). 100% Allowed Benefit for each ear (co-pays and deductible do not apply); member may be balance billed up to total charge. Hospitalization (Inpatient)/ Surgery Covered in full 30% Allowed Benefit after deductible Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. 30% Allowed Benefit after deductible Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $5 10 co-pay per visit. Office Setting – $30 co-pay after deductible Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for pre- and postnatal services. Delivery and hospitalization – 30% Allowed Benefit after deductible Outpatient Surgery $5 10 co-pay PCP; $10 15 co-pay specialist Office Setting – $30 PCP co-pay/$40 Specialist co-pay Physical Therapy $10 15 co-pay; 30 visits/per condition/per calendar year. PCP referral required. year Office Setting – $40 co-pay; limited to 30 days/condition/ benefit period; combined with speech & occupational therapy Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% up to a max of $50 self injectables Units 5 & 6: $75 self injectables MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% up to a max of $100 self injectables Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 self injectables RETAIL: $500 deductible, then: $15 generic/$35 preferred brand/$60 non-preferred brand; self-injectables – 50% coinsurance up to a max payment of $150 (30 days) MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $30 generic/$70 preferred brand/$120 non-preferred brand; self-injectables – 50% coinsurance up to a max payment of $300 (90 days) Routine Physicals No co-pay No co-pay Vision Care $10 co-pay through Xxxxx Vision Providers – Optometrists or Opthamologists. Limited to one examination per calendar year. Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. $10 co-pay through Xxxxx Vision Providers. Routine eye exam (limited to 1 visit/per year). Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. Well Child Care No co-pay No co-pay Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health Primary Care Office Visit Co-pays/ Specialist Office Visit Co-pays $5 10 co-pay $10 15 co-pay $30 co-pay after deductible $40 co-pay after deductible Calendar Year Deductible N/A Individual – $4,500 individual; family – $9,000 Co-insurance 100% Plan pays 70%; employee pays 30% Out-of-Pocket Maximum (Medical Only) Individual – $2,000; family – $6,000 Individual – $6,350; family – $12,700 Out-of-Pocket Max. (Comb. Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Calendar Year Maximum Unlimited Unlimited Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services Dependents must be added within 31 days of becoming eligible or wait until the next open enrollment period. • Dependents are covered until end of BlueChoice Triple Option “Open Access” Plan Xxxxx 0 Xxxxx 0 Xxxxx 0 $10 co-pay, 24 visits per calendar year $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 20 visits per year) $15 co-pay (unlimited visits) 80% Allowed Benefit after deductible (unlimited visits) $10 No co-pay covered for accidental bodily injury or to correct congenital anomalies 90% Allowed Benefit after deductible covered for accidental bodily injury or to correct congenital anomalies 80% Allowed Benefit after deductible Lab no co-pay (Lab Corp only) Other diagnostic – $10 co-pay (eg., MRIs). $15 co-pay 80% Allowed Benefit after deductible 100% Allowed Benefit 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible $50 65 co-pay (waived if admitted) Urgent Care Centers – $10 co-pay Considered under Level 1. If Benefits are not available under Xxxxx 0, benefits may be payable under the appropriate level. Urgent Care Centers – $15 co-pay 80% Allowed Benefit after deductible Processed under Xxxxx 0 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Hearing exam – no $10 co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Hearing exam – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. No co-pay 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. No co-pay 100% Allowed Benefit, no deductible 80% Allowed Benefit after deductible No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $10 co-pay per visit $10 co-pay per visit Deductible and co-insurance apply No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for prenatal services. Hospitalization covered at 90% of Allowed Benefit after deductible. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. $10 co-pay $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 30 visits/per condition/per year) $15 co-pay (limited to 100 visits per yearyear combined between Levels 2 and 3) 80% Allowed Benefit after deductible (limited to 100 visits per yearyear combined between Levels 2 and 3) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% up to a max of $50 self injectables Units 5 & 6: $75 self injectables MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% up to a max of $100 self injectables Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 self injectables No co-pay No co-pay 80% Allowed Benefit, no deductible $10 co-pay at Plan-designated Vision Care Centers (through Xxxxx Vision Providers)Providers – Optometrists or Opthamologists. Limited to one examination per calendar year. Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. Not Covered — refer to Level 1 benefits or the CareFirst Select Vision plan. No co-pay No co-pay 80% Allowed Benefit, no deductible Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health $10 co-pay $10 co-pay $15 co-pay $15 co-pay 80% Allowed Benefit, after deductible Individual/family – $0 Individual – $200; family – $400 Individual – $300; family – $600 100% 90% 80% Individual – $2,000; family – $6,000 Individual – $500; family – $1,000 Individual – $1,000; family – $2,000 Individual – $2,000; family – $4,000 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Unlimited Unlimited Unlimited Unlimited, except for fertility services Unlimited, except for fertility services Unlimited, except for fertility services the month in which they turn 26. • This chart is for comparison purposes only. Please consult each plan benefit summary (available on-line) for full details. Benefit CareFirst/BCBS Preferred ProviderNetwork (PPN) In-Network Out-of-Network Acupuncture Services Only covered with certain diagnosis. Contact BCBS to verify. $15 co-pay for preferred provider. Only covered with certain diagnosis. Contact BCBS to verify. 80% of Allowed Benefit, after deductible. Chiropractic Services $15 co-pay in-network network. Unlimited visits. Benefit paid at 80% of Allowed Benefit after deductible Dental Services as a result of an accidental injury Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Diagnostic, Lab Services, X-ray 100% of Allowed Benefit 80% of Allowed Benefit after deductible Durable Medical Equipment 100% of Allowed Benefit 80% of Allowed Benefit after deductible Emergency Room Visits $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay Family Planning/Fertility (subject to state mandate) Plan of treatment required Artificial Insemination – 100% of allowed mandate, some services may require co-pay; IVF – 100% of Allowed Benefit, some services may require co-pay (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Plan of treatment required Artificial Insemination – 80% of allowed benefit after deductible; IVF – 80% of Allowed Benefit after deductible (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam office setting – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear. Hospitalization (Inpatient)/ Surgery 100% up to 365 days 80% after deductible/365 days Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $15 co-pay per visit No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. Deductible and co-insurance applies80% of Allowed Benefit after deductible. Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. Outpatient Surgery 100% of Allowed Benefit 80% of Allowed Benefit after deductible Physical Therapy 100 visits per year with $15 co-pay per office visit Deductible, then 80% of Allowed Benefit for 100 visits per calendar year Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% up to a max of $50 self injectables | Units 5 & 6: $75 self injectables MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% up to a max of $100 self injectables | Units 5 & 6—4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 self injectables Routine Physicals No co-pay 80% of Allowed Benefit, after deductible Vision Care Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Well Child Care No co-pay 80% of Allowed Benefit, after deductible Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 Magellan Behavioral Health Primary Care Office Visit Co-pays/ Specialist Office Visits Co-pays 100% of Allowed Benefit after $15 100% of Allowed Benefit after $15 80/20 after deductible Calendar Year Deductible N/A Individual – $200; family – $400 Co-insurance 100% 80/20 Out-of-Pocket Max. (Medical Only) Individual – $1,200; family – $2,400 Individual – $1,200; family – $2,400 Out-of-Pocket Max. (Combined Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700

Active Employees. Our goal...to educate all employees so they can make an informed healthcare decision. Benefit BlueChoice (HMO) “Open Access” Plan BlueChoice (HMO) Low Option “Open Access” Plan Acupuncture Services $10 15 co-pay, 24 visits per calendar year Not covered (except when approved or authorized by plan when used for anesthesia) Chiropractic Services $10 15 co-pay, 20 visits per calendar year Office Setting – Deductible, then $40/visit; 20 visits per calendar year Dental Services as a result of an accidental injury $10 No co-pay – Covered for accidental bodily injury or to correct congenital anomalies 100% Allowed Benefit after deductible Diagnostic, Lab Services, X-ray Covered in full for x-rays and lab services (Lab Corp only) Other diagnostic – $10 15 co-pay (eg., MRIs) Non-routine, office setting; $40 co-pay/visit (Lab Corp only for lab services) Durable Medical Equipment 100% Allowed Benefit 50% Allowed Benefit after deductible Emergency Room Visits Medical Emergency – $50 85 co-pay, waived if admitted Urgent Care Centers – $10 PCP co-pay/$15 Specialist co-pay $300 co-pay after deductible (waived if admitted) Urgent Care Centers – $100 co-pay after deductible Family Planning/Fertility (subject to state mandate) Infertility Counseling & Testing – $10 co-pay Artificial Insemination – covered at 50% of the plan allowance; IVF – covered at 50% of the plan allowance (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) 50% Allowed Benefit after deductible; IVF – (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam – no $10 co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Covered for minor children (up to age 18). 100% Allowed Benefit for each ear (co-pays and deductible do not apply); member may be balance billed up to total charge. Hospitalization (Inpatient)/ Surgery Covered in full 30% Allowed Benefit after deductible Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. 30% Allowed Benefit after deductible Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $5 co-pay per visit. Office Setting – $30 co-pay after deductible Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for pre- and postnatal services. Delivery and hospitalization – 30% Allowed Benefit after deductible Outpatient Surgery $5 co-pay PCP; $10 co-pay specialist Office Setting – $30 PCP co-pay/$40 Specialist co-pay Physical Therapy $10 co-pay; 30 visits/per condition/per calendar year. PCP referral required. Office Setting – $40 co-pay; limited to 30 days/condition/ benefit period; combined with speech & occupational therapy Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 preferred brand/$25 non-preferred brand MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 preferred brand/$50 non-preferred brand Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE: $150 RETAIL: $500 deductible, then: $15 generic/$35 preferred brand/$60 non-preferred brand; self-injectables – 50% coinsurance up to a max payment of $150 (30 days) MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $30 generic/$70 preferred brand/$120 non-preferred brand; self-injectables – 50% coinsurance up to a max payment of $300 (90 days) Routine Physicals No co-pay No co-pay Vision Care $10 co-pay through Xxxxx Vision Providers – Optometrists or Opthamologists. Limited to one examination per calendar year. Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. $10 co-pay through Xxxxx Vision Providers. Routine eye exam (limited to 1 visit/per year). Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. Well Child Care No co-pay No co-pay Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health Primary Care Office Visit Co-pays/ Specialist Office Visit Co-pays $5 co-pay $10 co-pay $30 co-pay after deductible $40 co-pay after deductible Calendar Year Deductible N/A Individual – $4,500 individual; family – $9,000 Co-insurance 100% Plan pays 70%; employee pays 30% Out-of-Pocket Maximum (Medical Only) Individual – $2,000; family – $6,000 Individual – $6,350; family – $12,700 Out-of-Pocket Max. (Comb. Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Calendar Year Maximum Unlimited Unlimited Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services Dependents must be added within 31 days of becoming eligible or wait until the next open enrollment period. • Dependents are covered until end of BlueChoice Triple Option “Open Access” Plan Xxxxx 0 Xxxxx 0 Xxxxx 0 $10 co-pay, 24 visits per calendar year $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 20 visits per year) $15 co-pay (unlimited visits) 80% Allowed Benefit after deductible (unlimited visits) $10 co-pay covered for accidental bodily injury or to correct congenital anomalies 90% Allowed Benefit after deductible covered for accidental bodily injury or to correct congenital anomalies 80% Allowed Benefit after deductible Lab no co-pay (Lab Corp only) Other diagnostic – $10 co-pay (eg., MRIs). $15 co-pay 80% Allowed Benefit after deductible 100% Allowed Benefit 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible $50 co-pay (waived if admitted) Urgent Care Centers – $10 co-pay Considered under Level 1. If Benefits are not available under Xxxxx 0, benefits may be payable under the appropriate level. Urgent Care Centers – $15 co-pay 80% Allowed Benefit after deductible Processed under Xxxxx 0 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Hearing exam – no co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Hearing exam – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. No co-pay 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. No co-pay 100% Allowed Benefit, no deductible 80% Allowed Benefit after deductible No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $10 co-pay per visit $10 co-pay per visit Deductible and co-insurance apply No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for prenatal services. Hospitalization covered at 90% of Allowed Benefit after deductible. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. $10 co-pay $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 30 visits/per condition/per year) $15 co-pay (limited to 100 visits per year) 80% Allowed Benefit after deductible (limited to 100 visits per year) RETAIL: $5 generic/$15 preferred brand/$25 non-preferred brand MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 preferred brand/$50 non-preferred brand Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE: $150 No co-pay No co-pay 80% Allowed Benefit, no deductible $10 co-pay at Plan-designated Vision Care Centers (Xxxxx Vision Providers). Discounts on glasses and contact lenses from Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. Not Covered — refer to Level 1 benefits or the CareFirst Select Vision plan. No co-pay No co-pay 80% Allowed Benefit, no deductible Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health $10 co-pay $10 co-pay $15 co-pay $15 co-pay 80% Allowed Benefit, after deductible Individual/family – $0 Individual – $200; family – $400 Individual – $300; family – $600 100% 90% 80% Individual – $2,000; family – $6,000 Individual – $500; family – $1,000 Individual – $1,000; family – $2,000 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Unlimited Unlimited Unlimited Unlimited, except for fertility services Unlimited, except for fertility services Unlimited, except for fertility services the month in which they turn 26. • This chart is for comparison purposes only. Please consult each plan benefit summary (available on-line) for full details. Benefit CareFirst/BCBS Preferred ProviderNetwork (PPN) In-Network Out-of-Network Acupuncture Services Only covered with certain diagnosis. Contact BCBS to verify. $15 co-pay for preferred provider. Only covered with certain diagnosis. Contact BCBS to verify. 80% of Allowed Benefit, after deductible. Chiropractic Services $15 co-pay in-network Benefit paid at 80% of Allowed Benefit after deductible Dental Services as a result of an accidental injury Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Diagnostic, Lab Services, X-ray 100% of Allowed Benefit 80% of Allowed Benefit after deductible Durable Medical Equipment 100% of Allowed Benefit 80% of Allowed Benefit after deductible Emergency Room Visits $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay Family Planning/Fertility (subject to state mandate) Plan of treatment required Artificial Insemination – 100% of allowed mandate, some services may require co-pay; IVF – 100% of Allowed Benefit, some services may require co-pay (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Plan of treatment required Artificial Insemination – 80% of allowed benefit after deductible; IVF – 80% of Allowed Benefit after deductible (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear. Hospitalization (Inpatient)/ Surgery 100% up to 365 days 80% after deductible/365 days Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health for pre-authorization at 0-000-000-0000. Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. $15 co-pay per visit No pre-authorization required. Contact Magellan Behavioral Health for provider network information at 0-000-000-0000. Deductible and co-insurance applies. Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. Outpatient Surgery 100% of Allowed Benefit 80% of Allowed Benefit after deductible Physical Therapy 100 visits per year with $15 co-pay per office visit Deductible, then 80% of Allowed Benefit for 100 visits per calendar year Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 preferred brand/$25 non-preferred brand MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 preferred brand/$50 non-preferred brand Units 5 & 6—4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE: $150 Routine Physicals No co-pay 80% of Allowed Benefit, after deductible Vision Care Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Well Child Care No co-pay 80% of Allowed Benefit, after deductible Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 Magellan Behavioral Health Primary Care Office Visit Co-pays/ Specialist Office Visits Co-pays 100% of Allowed Benefit after $15 100% of Allowed Benefit after $15 80/20 after deductible Calendar Year Deductible N/A Individual – $200; family – $400 Co-insurance 100% 80/20 Out-of-Pocket Max. (Medical Only) Individual – $1,200; family – $2,400 Individual – $1,200; family – $2,400 Out-of-Pocket Max. (Combined Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700

Active Employees. Our goal...to educate all employees so they can make an informed healthcare decision. Benefit BlueChoice (HMO) “Open Access” Plan BlueChoice (HMO) Low Option “Open Access” Plan Acupuncture Services $10 15 co-pay, 24 visits per calendar year Not covered (except when approved or authorized by plan when used for anesthesia) Chiropractic Services $10 15 co-pay, 20 visits per calendar year Office Setting – Deductible, then $40/visit; 20 visits per calendar year Dental Services as a result of an accidental injury $10 No co-pay – Covered for accidental bodily injury or to correct congenital anomalies 100% Allowed Benefit after deductible Diagnostic, Lab Services, X-ray Covered in full for x-rays and lab services (Lab Corp only) Other diagnostic – $10 15 co-pay (eg., MRIs) Non-routine, office setting; $40 co-pay/visit (Lab Corp only for lab services) Durable Medical Equipment 100% Allowed Benefit 50% Allowed Benefit after deductible Emergency Room Visits Medical Emergency – $50 75 co-pay, waived if admitted Urgent Care Centers – $10 PCP co-pay/$15 Specialist co-pay $300 co-pay after deductible (waived if admitted) Urgent Care Centers – $100 co-pay after deductible Family Planning/Fertility (subject to state mandate) Infertility Counseling & Testing – $10 co-pay Artificial Insemination – covered at 50% of the plan allowance; IVF – covered at 50% of the plan allowance (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) 50% Allowed Benefit after deductible; IVF – (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam – no $10 co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Covered for minor children (up to age 18). 100% Allowed Benefit for each ear (co-pays and deductible do not apply); member may be balance billed up to total charge. Hospitalization (Inpatient)/ Surgery Covered in full 30% Allowed Benefit after deductible Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health CareFirst Assist for pre-authorization at 0-000-000-0000. Contact Magellan Behavioral Health CareFirst Assist for pre-authorization at 01-000800-000-0000245- 7013. 30% Allowed Benefit after deductible Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health CareFirst Assist for provider network information at 0-000-000-0000. $5 10 co-pay per visit. Office Setting – $30 co-pay after deductible Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for pre- and postnatal services. Delivery and hospitalization – 30% Allowed Benefit after deductible Outpatient Surgery $5 10 co-pay PCP; $10 15 co-pay specialist Office Setting – $30 PCP co-pay/$40 Specialist co-pay Physical Therapy $10 15 co-pay; 30 visits/per condition/per calendar year. PCP referral required. year Office Setting – $40 co-pay; limited to 30 days/condition/ benefit period; combined with speech & occupational therapy Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% coinsurance up to a max of $65 specialty* Units 5 & 6: $75 specialty* MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% coinsurance up to a max of $130 specialty* Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 specialty* * Specialty may require pre-authorization RETAIL: $500 deductible, then: $15 generic/$35 preferred brand/$60 non-preferred brand; self-injectables specialty* – 50% coinsurance up to a max payment of $150 (30 days) MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $30 generic/$70 preferred brand/$120 non-preferred brand; self-injectables specialty* – 50% coinsurance up to a max payment of $300 (90 days) * Specialty may require pre-authorization Routine Physicals No co-pay No co-pay Vision Care $10 co-pay through Xxxxx Vision Providers – Optometrists or Opthamologists. Limited to one examination per calendar year. Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. $10 co-pay through Xxxxx Vision Providers. Routine eye exam (limited to 1 visit/per year). Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. Well Child Care No co-pay No co-pay Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health CareFirst Assist Primary Care Office Visit Co-pays/ Specialist Office Visit Co-pays $5 10 co-pay $10 15 co-pay $30 co-pay after deductible $40 co-pay after deductible Calendar Year Deductible N/A Individual – $4,500 individual; family – $9,000 Co-insurance 100% Plan pays 70%; employee pays 30% Out-of-Pocket Maximum (Medical Only) Individual – $2,000; family – $6,000 Individual – $6,350; family – $12,700 Out-of-Pocket Max. (Comb. Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Calendar Year Maximum Unlimited Unlimited Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services Dependents must be added within 31 days of becoming eligible or wait until the next open enrollment period. • Dependents are covered until end of BlueChoice Triple Option “Open Access” Plan Xxxxx 0 Xxxxx 0 Xxxxx 0 $10 co-pay, 24 visits per calendar year $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 20 visits per year) $15 co-pay (unlimited visits) 80% Allowed Benefit after deductible (unlimited visits) $10 No co-pay covered for accidental bodily injury or to correct congenital anomalies 90% Allowed Benefit after deductible covered for accidental bodily injury or to correct congenital anomalies 80% Allowed Benefit after deductible Lab no co-pay (Lab Corp only) Other diagnostic – $10 co-pay (eg., MRIs). $15 co-pay 80% Allowed Benefit after deductible 100% Allowed Benefit 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible $50 75 co-pay (waived if admitted) Urgent Care Centers – $10 co-pay Considered under Level 1. If Benefits are not available under Xxxxx 0, benefits may be payable under the appropriate level. Urgent Care Centers – $15 co-pay 80% Allowed Benefit after deductible Processed under Xxxxx 0 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Hearing exam – no $10 co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Hearing exam – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. No co-pay 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Contact Magellan Behavioral Health CareFirst Assist for pre-authorization at 0-000-000-0000. No co-pay 100% Allowed Benefit, no deductible 80% Allowed Benefit after deductible No pre-authorization required. Contact Magellan Behavioral Health CareFirst Assist for provider network information at 0-000-000-0000. $10 co-pay per visit $10 co-pay per visit Deductible and co-insurance apply No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for prenatal services. Hospitalization covered at 90% of Allowed Benefit after deductible. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. $10 co-pay $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 30 visits/per condition/per year) $15 co-pay (limited to 100 visits per yearyear combined between Levels 2 and 3) 80% Allowed Benefit after deductible (limited to 100 visits per yearyear combined between Levels 2 and 3) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% coinsurance up to a max of $65 specialty (may require pre-authorization) Units 5 & 6: $75 specialty (may require pre-authorization) MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% coinsurance up to a max of $130 specialty (may require pre-authorization) Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 specialty (may require pre-authorization) No co-pay No co-pay 80% Allowed Benefit, no deductible $10 co-pay at Plan-designated Vision Care Centers (through Xxxxx Vision Providers)Providers – Optometrists or Opthamologists. Limited to one examination per calendar year. Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. Not Covered — refer to Level 1 benefits or the CareFirst Select Vision plan. No co-pay No co-pay 80% Allowed Benefit, no deductible Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health CareFirst Assist $10 co-pay $10 co-pay $15 co-pay $15 co-pay 80% Allowed Benefit, after deductible Individual/family – $0 Individual – $200; family – $400 Individual – $300; family – $600 100% 90% 80% Individual – $2,000; family – $6,000 Individual – $5002,000; family – $1,000 4,000 Individual – $1,0002,000; family – $2,000 4,000 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Unlimited Unlimited Unlimited Unlimited, except for fertility services Unlimited, except for fertility services Unlimited, except for fertility services the month in which they turn 26. • This chart is for comparison purposes only. Please consult each plan benefit summary (available on-line) for full details. Benefit CareFirst/BCBS Preferred ProviderNetwork (PPN) In-Network Out-of-Network Acupuncture Services Only covered with certain diagnosis. Contact BCBS to verify. $15 co-pay for preferred provider. Only covered with certain diagnosis. Contact BCBS to verify. 80% of Allowed Benefit, after deductible. Chiropractic Services $15 co-pay in-network network. Unlimited visits. Benefit paid at 80% of Allowed Benefit after deductible Dental Services as a result of an accidental injury Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Diagnostic, Lab Services, X-ray 100% of Allowed Benefit 80% of Allowed Benefit after deductible Durable Medical Equipment 100% of Allowed Benefit 80% of Allowed Benefit after deductible Emergency Room Visits $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay Family Planning/Fertility (subject to state mandate) Plan of treatment required Artificial Insemination – 100% of allowed mandate, some services may require co-pay; IVF – 100% of Allowed Benefit, some services may require co-pay (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Plan of treatment required Artificial Insemination – 80% of allowed benefit after deductible; IVF – 80% of Allowed Benefit after deductible (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam office setting – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear. Hospitalization (Inpatient)/ Surgery 100% up to 365 days 80% after deductible/365 days Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health CareFirst Assist for pre-authorization at 0-000-000-0000. Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health CareFirst Assist for provider network information at 0-000-000-0000. $15 co-pay per visit No pre-authorization required. Contact Magellan Behavioral Health CareFirst Assist for provider network information at 0-000-000-0000. Deductible and co-insurance applies80% of Allowed Benefit after deductible. Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. Outpatient Surgery 100% of Allowed Benefit 80% of Allowed Benefit after deductible Physical Therapy 100 visits per year with $15 co-pay per office visit Deductible, then 80% of Allowed Benefit for 100 visits per calendar year Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% coinsurance up to a max of $65 specialty* | Units 5 & 6: $75 specialty* MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% coinsurance up to a max of $130 specialty* | Units 5 & 6—4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 specialty* * Specialty may require pre-authorization Routine Physicals No co-pay 80% of Allowed Benefit, after deductible Vision Care Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Well Child Care No co-pay 80% of Allowed Benefit, after deductible Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 Magellan Behavioral Health CareFirst Assist Primary Care Office Visit Co-pays/ Specialist Office Visits Co-pays 100% of Allowed Benefit after $15 100% of Allowed Benefit after $15 80/20 after deductible Calendar Year Deductible N/A Individual – $200; family – $400 Co-insurance 100% 80/20 Out-of-Pocket Max. (Medical Only) Individual – $1,200; family – $2,400 Individual – $1,200; family – $2,400 Out-of-Pocket Max. (Combined Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700

Active Employees. Our goal...to educate all employees so they can make an informed healthcare decision. Benefit BlueChoice (HMO) “Open Access” Plan BlueChoice (HMO) Low Option “Open Access” Plan Acupuncture Services $10 15 co-pay, 24 visits per calendar year Not covered (except when approved or authorized by plan when used for anesthesia) Chiropractic Services $10 15 co-pay, 20 visits per calendar year Office Setting – Deductible, then $40/visit; 20 visits per calendar year Dental Services as a result of an accidental injury $10 No co-pay – Covered for accidental bodily injury or to correct congenital anomalies 100% Allowed Benefit after deductible Diagnostic, Lab Services, X-ray Covered in full for x-rays and lab services (Lab Corp only) Other diagnostic – $10 15 co-pay (eg., MRIs) Non-routine, office setting; $40 co-pay/visit (Lab Corp only for lab services) Durable Medical Equipment 100% Allowed Benefit 50% Allowed Benefit after deductible Emergency Room Visits Medical Emergency – $50 85 co-pay, waived if admitted Urgent Care Centers – $10 PCP co-pay/$15 Specialist co-pay $300 co-pay after deductible (waived if admitted) Urgent Care Centers – $100 co-pay after deductible Family Planning/Fertility (subject to state mandate) Infertility Counseling & Testing – $10 co-pay Artificial Insemination – covered at 50% of the plan allowance; IVF – covered at 50% of the plan allowance (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) 50% Allowed Benefit after deductible; IVF – (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam – no $10 co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Covered for minor children (up to age 18). 100% Allowed Benefit for each ear (co-pays and deductible do not apply); member may be balance billed up to total charge. Hospitalization (Inpatient)/ Surgery Covered in full 30% Allowed Benefit after deductible Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health CareFirst Assist for pre-authorization at 0-000-000-0000. Contact Magellan Behavioral Health CareFirst Assist for pre-authorization at 01-000800- 245-000-00007013. 30% Allowed Benefit after deductible Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health CareFirst Assist for provider network information at 0-000-000-0000. $5 10 co-pay per visit. Office Setting – $30 co-pay after deductible Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for pre- and postnatal services. Delivery and hospitalization – 30% Allowed Benefit after deductible Outpatient Surgery $5 10 co-pay PCP; $10 15 co-pay specialist Office Setting – $30 PCP co-pay/$40 Specialist co-pay Physical Therapy $10 15 co-pay; 30 visits/per condition/per calendar year. PCP referral required. year Office Setting – $40 co-pay; limited to 30 days/condition/ benefit period; combined with speech & occupational therapy Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% coinsurance up to a max of $75 specialty* Units 5 & 6: $75 specialty* MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% coinsurance up to a max of $150 specialty* Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 specialty* * Specialty may require pre-authorization RETAIL: $500 deductible, then: $15 generic/$35 preferred brand/$60 non-preferred brand; self-injectables specialty* – 50% coinsurance up to a max payment of $150 (30 days) MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $30 generic/$70 preferred brand/$120 non-preferred brand; self-injectables specialty* – 50% coinsurance up to a max payment of $300 (90 days) * Specialty may require pre-authorization Routine Physicals No co-pay No co-pay Vision Care $10 co-pay through Xxxxx Vision Providers – Optometrists or Opthamologists. Limited to one examination per calendar year. Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. $10 co-pay through Xxxxx Vision Providers. Routine eye exam (limited to 1 visit/per year). Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. Well Child Care No co-pay No co-pay Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health CareFirst Assist Primary Care Office Visit Co-pays/ Specialist Office Visit Co-pays $5 10 co-pay $10 15 co-pay $30 co-pay after deductible $40 co-pay after deductible Calendar Year Deductible N/A Individual – $4,500 individual; family – $9,000 Co-insurance 100% Plan pays 70%; employee pays 30% Out-of-Pocket Maximum (Medical Only) Individual – $2,000; family – $6,000 Individual – $6,350; family – $12,700 Out-of-Pocket Max. (Comb. Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Calendar Year Maximum Unlimited Unlimited Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services Dependents must be added within 31 days of becoming eligible or wait until the next open enrollment period. • Dependents are covered until end of the BlueChoice Triple Option “Open Access” Plan Xxxxx 0 Xxxxx 0 Xxxxx 0 $10 co-pay, 24 visits per calendar year $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 20 visits per year) $15 co-pay (unlimited visits) 80% Allowed Benefit after deductible (unlimited visits) $10 No co-pay covered for accidental bodily injury or to correct congenital anomalies 90% Allowed Benefit after deductible covered for accidental bodily injury or to correct congenital anomalies 80% Allowed Benefit after deductible Lab no co-pay (Lab Corp only) Other diagnostic – $10 co-pay (eg., MRIs). $15 co-pay 80% Allowed Benefit after deductible 100% Allowed Benefit 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible $50 85 co-pay (waived if admitted) Urgent Care Centers – $10 co-pay Considered under Level 1. If Benefits are not available under Xxxxx 0, benefits may be payable under the appropriate level. Urgent Care Centers – $15 co-pay 80% Allowed Benefit after deductible Processed under Xxxxx 0 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Hearing exam – no $10 co-pay. Aids – 100% Allowed Benefit for each ear; member may be balance billed up to total charge. Benefit once every 36 months. Hearing exam – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear; member may be balance billed up to total charge. No co-pay 90% Allowed Benefit after deductible 80% Allowed Benefit after deductible Contact Magellan Behavioral Health CareFirst Assist for pre-authorization at 0-000-000-0000. No co-pay 100% Allowed Benefit, no deductible 80% Allowed Benefit after deductible No pre-authorization required. Contact Magellan Behavioral Health CareFirst Assist for provider network information at 0-000-000-0000. $10 co-pay per visit $10 co-pay per visit Deductible and co-insurance apply No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. No co-pays required for prenatal services. Hospitalization covered at 90% of Allowed Benefit after deductible. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. $10 co-pay $15 co-pay 80% Allowed Benefit after deductible $10 co-pay (limited to 30 visits/per condition/per year) $15 co-pay (limited to 100 visits per yearyear combined between Levels 2 and 3) 80% Allowed Benefit after deductible (limited to 100 visits per yearyear combined between Levels 2 and 3) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% coinsurance up to a max of $75 specialty (may require pre-authorization) Units 5 & 6: $75 specialty (may require pre-authorization) MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% coinsurance up to a max of $150 specialty (may require pre-authorization) Units 5 & 6 – 4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 specialty (may require pre-authorization) No co-pay No co-pay 80% Allowed Benefit, no deductible $10 co-pay at Plan-designated Vision Care Centers (through Xxxxx Vision Providers)Providers – Optometrists or Opthamologists. Limited to one examination per calendar year. Discounts on glasses and contact lenses from participating Xxxxx Vision Providers. You may also use your CareFirst Select Vision plan. Not Covered — refer to Level 1 benefits or the CareFirst Select Vision plan. No co-pay No co-pay 80% Allowed Benefit, no deductible Disease Management/Case Management • Discount program through Blue 365 • Magellan Behavioral Health CareFirst Assist $10 co-pay $10 co-pay $15 co-pay $15 co-pay 80% Allowed Benefit, after deductible Individual/family – $0 Individual – $200; family – $400 Individual – $300; family – $600 100% 90% 80% Individual – $2,000; family – $6,000 Individual – $5002,000; family – $1,000 6,000 Individual – $1,0002,000; family – $2,000 6,000 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700 Unlimited Unlimited Unlimited Unlimited, except for fertility services Unlimited, except for fertility services Unlimited, except for fertility services the month in which they turn 26. • This chart is for comparison purposes only. Please consult each plan benefit summary (available on-line) for full details. Benefit CareFirst/BCBS Preferred ProviderNetwork (PPN) In-Network Out-of-Network Acupuncture Services Only covered with certain diagnosis. Contact BCBS to verify. $15 co-pay for preferred provider. Only covered with certain diagnosis. Contact BCBS to verify. 80% of Allowed Benefit, after deductible. Chiropractic Services $15 co-pay in-network network. Unlimited visits. Benefit paid at 80% of Allowed Benefit after deductible Dental Services as a result of an accidental injury Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Restorative services for accidental injury to natural teeth–100% of Allowed Benefit Diagnostic, Lab Services, X-ray 100% of Allowed Benefit 80% of Allowed Benefit after deductible Durable Medical Equipment 100% of Allowed Benefit 80% of Allowed Benefit after deductible Emergency Room Visits $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay $25 co-pay or if admitted 100% of Allowed Benefit. Urgent Care Centers – $15 co-pay Family Planning/Fertility (subject to state mandate) Plan of treatment required Artificial Insemination – 100% of allowed mandate, some services may require co-pay; IVF – 100% of Allowed Benefit, some services may require co-pay (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Plan of treatment required Artificial Insemination – 80% of allowed benefit after deductible; IVF – 80% of Allowed Benefit after deductible (limited to 3 attempts per live birth, lifetime maximum benefit $100,000) Hearing Exams/Hearing Aids Hearing exam office setting – $15 co-pay. 100% of Allowed Benefit every 36 months per aid per ear. Hearing exam – 80% of Allowed Benefit, after deductible. 100% of Allowed Benefit every 36 months per aid per ear. Hospitalization (Inpatient)/ Surgery 100% up to 365 days 80% after deductible/365 days Inpatient Nervous and Mental; Alcohol/Substance Abuse Contact Magellan Behavioral Health CareFirst Assist for pre-authorization at 0-000-000-0000. Outpatient Nervous and Mental; Alcohol/Substance Abuse No pre-authorization required. Contact Magellan Behavioral Health CareFirst Assist for provider network information at 0-000-000-0000. $15 co-pay per visit No pre-authorization required. Contact Magellan Behavioral Health CareFirst Assist for provider network information at 0-000-000-0000. Deductible and co-insurance applies80% of Allowed Benefit after deductible. Maternity Care No co-pays required for prenatal services. Hospitalization covered at 100% of Allowed Benefit. Prenatal services and hospitalization covered at 80% of Allowed Benefit after deductible. Outpatient Surgery 100% of Allowed Benefit 80% of Allowed Benefit after deductible Physical Therapy 100 visits per year with $15 co-pay per office visit Deductible, then 80% of Allowed Benefit for 100 visits per calendar year Prescription Drug Card (CVS CAREMARK) (includes diabetic supplies) RETAIL: $5 generic/$15 generic/$20 preferred brand/$25 brand/$35 non-preferred brand Units 1–4: 50% coinsurance up to a max of $75 specialty* | Units 5 & 6: $75 specialty* MAIL ORDER or CVS RETAIL MAINTENANCE CHOICE: $10 generic/$30 generic/$40 preferred brand/$50 brand/$70 non-preferred brand Units 1–4: 50% coinsurance up to a max of $150 specialty* | Units 5 & 6—4th tier specialty: RETAIL: $75 MAIL ORDER/ MAINTENANCE CHOICE6: $150 specialty* * Specialty may require pre-authorization Routine Physicals No co-pay 80% of Allowed Benefit, after deductible Vision Care Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Not included in medical benefit. See CareFirst BCBS Summary Dental and Vision Plans. Well Child Care No co-pay 80% of Allowed Benefit, after deductible Additional Program Benefits Disease Management/Case Management • Discount program through Blue 365 Magellan Behavioral Health CareFirst Assist Primary Care Office Visit Co-pays/ Specialist Office Visits Co-pays 100% of Allowed Benefit after $15 100% of Allowed Benefit after $15 80/20 after deductible Calendar Year Deductible N/A Individual – $200; family – $400 Co-insurance 100% 80/20 Out-of-Pocket Max. (Medical Only) Individual – $1,200; family – $2,400 Individual – $1,200; family – $2,400 Out-of-Pocket Max. (Combined Medical & Rx) Individual – $6,350; family – $12,700 Individual – $6,350; family – $12,700