Common use of Advantage Benefit Chart for Services Incurred During Plan Years 2020 and 2021 Clause in Contracts

Advantage Benefit Chart for Services Incurred During Plan Years 2020 and 2021. 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Deductible for all services except drugs and preventive care (S/F) $250/$500 $400/$800 $750/$1,500 $1,500/$3,000 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Office visit copay/urgent care (copay waived for preventive services) For 2020: 1) Having taken health assessment and opted-in for health coaching 2) Not having taken health assessment or not having opted-in for health coaching For 2021: The incentive is changed and the only available copay option is copay #2. 1) $30 2) $35 1) $35 2) $40 1) $65 2) $70 1) $85 2) $90 In-Network Convenience Clinics and Online Care (deductible waived) $0 $0 $0 $0 Emergency room copay $100 $100 $100 N/A – subject to Deductible and 25% Coinsurance to OOP maximum Facility copays • Per inpatient admission (waived for admission to Center of Excellence) • Per outpatient surgery $100 $60 $200 $120 $500 $250 N/A – subject to Deductible and 25% Coinsurance to OOP maximum N/A – subject to Deductible and 25% Coinsurance to OOP maximum 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Coinsurance for MRI/CT scan services 10% 15% 25% N/A – subject to Deductible and 30% Coinsurance to OOP maximum Coinsurance for services NOT subject to copays 5% (95% coverage after payment of deductible) 5% (95% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible Coinsurance for lab, pathology and X-ray (not included as part of preventive care and not subject to office visit or facility copayments) 10% (90% coverage after payment of deductible) 10% (90% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible Coinsurance for durable medical equipment 20% (80% coverage after payment of 20% coinsurance) 20% (80% coverage after payment of 20% coinsurance) 20% (80% coverage after payment of 20% coinsurance) 25% for all services to OOP maximum after deductible Copay for three-tier prescription drug plan Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Maximum drug out- of-pocket limit (S/F) $1,050/$2,100 $1,050/$2,100 $1,050/$2,100 $1,050/$2,100 Maximum non-drug out-of-pocket limit (S/F) $1,700/$3,400 $1,700/$3,400 $2,400/$4,800 $3,600/$7,200

Advantage Benefit Chart for Services Incurred During Plan Years 2020 and 2021. 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Deductible for all services except drugs and preventive care (S/F) $250/$500 $400/$800 $750/$1,500 $1,500/$3,000 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Office visit copay/copay/ urgent care (copay waived for preventive services) For 2020: 2020 1) Having taken health assessment and opted-in for health coaching 2) Not having taken health assessment or not having opted-in for health coaching coaching. For 2021: 2021 The incentive is changed and the only available copay option is copay #2. 1) $30 2) $35 1) $35 2) $40 1) $65 2) $70 1) $85 2) $90 In-Network Convenience Clinics and Online Care (deductible waived) $0 $0 $0 $0 Emergency room copay $100 $100 $100 N/A – subject to Deductible and 25% Coinsurance to OOP maximum Facility copays • Per inpatient admission (waived for admission to Center of Excellence) • Per outpatient surgery $100 $60 $200 $120 $500 $250 N/A – subject to Deductible and 25% Coinsurance to OOP maximum N/A – subject to Deductible and 25% Coinsurance to OOP maximum 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Coinsurance for MRI/CT scan services 10% 15% 25% N/A – subject to Deductible and 30% Coinsurance to OOP maximum Coinsurance for services NOT subject to copays 5% (95% coverage after payment of deductible) 5% (95% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible Coinsurance for lab, pathology and X-ray (not included as part of preventive care and not subject to office visit or facility copayments) 10% (90% coverage after payment of deductible) 10% (90% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible Coinsurance for durable medical equipment 20% (80% coverage after payment of 20% coinsurance) 20% (80% coverage after payment of 20% coinsurance) 20% (80% coverage after payment of 20% coinsurance) 25% for all services to OOP maximum after deductible Copay for three-tier prescription drug plan Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Maximum drug out- of-pocket limit (S/F) $1,050/$2,100 $1,050/$2,100 $1,050/$2,100 $1,050/$2,100 Maximum non-drug out-of-pocket limit (S/F) $1,700/$3,400 $1,700/$3,400 $2,400/$4,800 $3,600/$7,200

Advantage Benefit Chart for Services Incurred During Plan Years 2020 and 2021. 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Deductible for all services except drugs and preventive care (S/F) $250/$500 $400/$800 $750/$1,500 $1,500/$3,000 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Office visit copay/copay/ urgent care (copay waived for preventive services) For 2020: 2020 1) Having taken health assessment and opted-in for health coaching 2) Not having taken health assessment or not having opted-in for health coaching coaching. For 2021: 2021 The incentive is changed and the only available copay option is copay #2. 1) $30 2) $35 1) $35 2) $40 1) $65 2) $70 1) $85 2) $90 In-Network Convenience Clinics and Online Care (deductible waived) $0 $0 $0 $0 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Emergency room copay $100 $100 $100 N/A – subject to Deductible and 25% Coinsurance to OOP maximum Facility copays • Per inpatient admission (waived for admission to Center of Excellence) • Per outpatient surgery $100 $60 $200 $120 $500 $250 N/A – subject to Deductible and 25% Coinsurance to OOP maximum N/A – subject to Deductible and 25% Coinsurance to OOP maximum 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Coinsurance for MRI/CT scan services 10% 15% 25% N/A – subject to Deductible and 30% Coinsurance to OOP maximum Coinsurance for services NOT subject to copays 5% (95% coverage after payment of deductible) 5% (95% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible Coinsurance for lab, pathology and X-ray (not included as part of preventive care and not subject to office visit or facility copayments) 10% (90% coverage after payment of deductible) 10% (90% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Coinsurance for durable medical equipment 20% (80% coverage after payment of 20% coinsurancecoinsuranc e) 20% (80% coverage after payment of 20% coinsurancecoinsuranc e) 20% (80% coverage after payment of 20% coinsurance) 25% for all services to OOP maximum after deductible Copay for three-tier prescription drug plan Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Maximum drug out-of- pocket limit (S/F) $1,050/ $2,100 $1,050/ $2,100 $1,050/ $2,100 $1,050/ $2,100 Maximum non-drug out- of-pocket limit (S/F) $1,050/$2,100 1,700/ $1,050/$2,100 3,400 $1,050/$2,100 1,700/ $1,050/$2,100 Maximum non-drug out-of-pocket limit (S/F) 3,400 $1,700/$3,400 2,400/ $1,700/$3,400 4,800 $2,400/$4,800 3,600/ $3,600/$7,2007,200

Advantage Benefit Chart for Services Incurred During Plan Years 2020 and 2021. 2020 and 2021 Benefit Provision Benefit Level 1 The the member pays: Benefit Level 2 The the member pays: Benefit Level 3 The the member pays: Benefit Level 4 The the member pays: Deductible for all services except drugs and preventive care (S/F) $250/$500 250/ $400/$800 500 $750/$1,500 400/ $1,500/$3,000 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: 800 $750/ $1,500 $1,500/ $3,000 Office visit copay/copay/ urgent care (copay waived for preventive services) For 2020: 2020 1) Having taken health assessment and opted-in for health coaching 2) Not having taken health assessment or not having opted-in for health coaching For 2021: 2021 The incentive is changed and the only available copay option is copay #2. 1) $30 2) $35 1) $35 2) $40 1) $65 2) $70 1) $85 2) $90 In-Network Convenience Clinics and Online Care (deductible waived) $0 $0 $0 $0 Emergency room copay $100 $100 $100 N/A – subject to Deductible and 25% Coinsurance to OOP maximum 2020 and 2021 Benefit Provision Benefit Level 1 the member pays: Benefit Level 2 the member pays: Benefit Level 3 the member pays: Benefit Level 4 the member pays: Facility copays • Per inpatient admission (waived for admission to Center of Excellence) • Per outpatient surgery $100 $60 $200 $120 $500 $250 N/A – subject to Deductible and 25% Coinsurance to OOP maximum N/A – subject to Deductible and 25% Coinsurance to OOP maximum 2020 and 2021 Benefit Provision Benefit Level 1 The member pays: Benefit Level 2 The member pays: Benefit Level 3 The member pays: Benefit Level 4 The member pays: Coinsurance for MRI/CT scan services 10% 15% 25% N/A – subject to Deductible and 30% Coinsurance to OOP maximum Coinsurance for services NOT subject to copays 5% (95% coverage after payment of deductible) 5% (95% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible Coinsurance for lab, pathology and X-ray (not included as part of preventive care and not subject to office visit or facility copayments) 10% (90% coverage after payment of deductible) 10% (90% coverage after payment of deductible) 20% (80% coverage after payment of deductible) 25% for all services to OOP maximum after deductible Coinsurance for durable medical equipment 20% (80% coverage after payment of 20% coinsurance) 20% (80% coverage after payment of 20% coinsurance) 20% (80% coverage after payment of 20% coinsurance) 25% for all services to OOP maximum after deductible Copay for three-tier prescription drug plan Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Tier 1: $18 Tier 2: $30 Tier 3: $55 Maximum drug out- of-pocket limit (S/F) $1,050/$2,100 1,050/ $1,050/$2,100 2,100 $1,050/$2,100 1,050/ $1,050/$2,100 2,100 $1,050/ $2,100 $1,050/ $2,100 2020 and 2021 Benefit Provision Benefit Level 1 the member pays: Benefit Level 2 the member pays: Benefit Level 3 the member pays: Benefit Level 4 the member pays: Maximum non-drug out-of-pocket limit (S/F) $1,700/$3,400 1,700/ $1,700/$3,400 3,400 $2,400/$4,800 1,700/ $3,600/$7,2003,400 $2,400/ $4,800 $3,600/ $7,200