Common use of Benefit Summary Clause in Contracts

Benefit Summary. Medical/Prescription Norton City Schools Blue Access® (PPO) Covered Benefits Network Non-Network Deductible (Single/Family) $1,100/$2,200*(see wellness) $1,400/$2,800* (see wellness) Out-of-Pocket Limit (Single/Family) $1,900/$3,800* (see wellness) $2,800/$5,600* (see wellness) Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: 🞈 allergy injections (PCP and SCP) 🞈 allergy testing 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, 🞈 Non-maternity related Ultrasounds and pharmaceutical products $30/$40 $10 10% 10% 30% 30% 30% 30% Preventive Care Services Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations1, Annual diabetic eye exam, Vision and Hearing screenings 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility No copayment/coinsurance No copayment/coinsurance 30% 30% Emergency and Urgent Care Emergency Room Services 🞈 facility/other covered services (copayment waived if admitted) Urgent Care Center Services 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-maternity related Ultrasounds and pharmaceutical products 🞈 Allergy injections 🞈 Allergy testing $150 $40 10% $10 10% $150 30% 30% 30% 30% Inpatient and Outpatient Professional Services Include but are not limited to: 🞈 Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams 10% 30% Inpatient Facility Services (Network/Non-Network combined) Unlimited days except for: 🞈 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 🞈 120 days for skilled nursing facility 10% 30% Covered Benefits Network Non-Network Outpatient Surgery Hospital/Alternative Care Facility 🞈 Surgery and administration of general anesthesia 10% 30% Other Outpatient Services (Combined Network & Non- Network limits) including but not limited to: 🞈 Non Surgical Outpatient Services for example: MRIs, C-Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatient services. 🞈 Home Care Services 90 visits (excludes IV Therapy) 🞈 Durable Medical Equipment and Orthotics 🞈 Prosthetic Devices 🞈 Prosthetic Limbs 🞈 Physical Medicine Therapy Day Rehabilitation programs 🞈 Hospice Care 🞈 Ambulance Services 10% 10% 10% 30% 10% 10% Outpatient Therapy Services (Combined Network & Non-Network limits) 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility Limits apply to: 🞈 Cardiac Rehabilitation Unlimited 🞈 Pulmonary Rehabilitation Unlimited 🞈 Physical Therapy: 30 visits 🞈 Occupational Therapy: 30 visits 🞈 Manipulation Therapy: 30 visits 🞈 Speech therapy: 30 visits $30/$40 10% 30% 30% Accidental Dental: unlimited Copayments/Coinsurance based on setting where covered services are received 30% Behavioral Health: Mental Illness and Substance Abuse2 🞈 Inpatient Facility Services 🞈 Inpatient Professional Services 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services. Outpatient Facility @ Hospital/Alternative Care Facility, Outpatient Professional 10% 10% $30/$30 10% 30% 30% 30% 30% Human Organ and Tissue Transplants3 🞈 Acquisition and transplant procedures, harvest and storage. 10% 30% Covered Benefits Network Non-Network Prescription Drugs Network Tier structure equals 1/2/3 /4 🞈 Network Retail Pharmacies: (30-day supply) 🞈 Anthem Rx Direct Mail Service: (90-day supply) $10/$25/$50/10% max $1500 $20/$50/$100 Out of Pocket Limit: None 50%, min $30 5 Not covered Medicare Rx - Wrap Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits.

Benefit Summary. Medical/Prescription Norton City Schools Blue Access® (PPO) Covered Benefits Network Non-Network Deductible (Single/Family) $1,100/$2,200*(see wellness) $1,400/$2,800* (see wellness) Out-of-Pocket Limit (Single/Family) $1,900/$3,800* (see wellness) $2,800/$5,600* (see wellness) Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: 🞈 allergy injections (PCP and SCP) � � allergy testing  🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, 🞈 Non-maternity related Ultrasounds and pharmaceutical products $30/$40 $10 10% 10% 30% 30% 30% 30% Preventive Care Services Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations1, Annual diabetic eye exam, Vision and Hearing screening s 🞈 Physician Home and Office Visits (PCP/SC P) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility No copayment/coinsurance No copayment/coinsurance 30% 30% Emergency and Urgent Care Emergency Room Servi ces 🞈 facility/other covered services (copayment waived if admitted) Urgent Care Center Serv ices 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-maternity related Ultrasounds and pharmaceutical pro ducts 🞈 Allergy inje ctions 🞈 Allergy testing $150 $40 10% $10 10% $150 30% 30% 30% 30% Inpatient and Outpatient Professional Services Include but are not limi ted to: 🞈 Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams 10% 30% Inpatient Facility Services (Network/Non-Network combined) Unlimited days exc ept for: 🞈 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatie nt basis) 🞈 120 days for skilled nursing facility 10% 30% Covered Benefits Network Non-Network Outpatient Surgery Hospital/Alternative Car e Facility 🞈 Surgery and administration of general anesthesia 10% 30% Other Outpatient Services (Combined Network & Non- Network limits) including but not  limited to: 🞈 Non Surgical Outpatient Services for example: MRIs, C-Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatie nt services. 🞈 Home Care Services 90 visits (exclude s IV Therapy) 🞈 Durable Medical Equipment and Orthotics 🞈 Pro sthetic Devices ��  Prosthetic Limbs 🞈 Physical Medicine Therapy Day Rehabi litation progra ms 🞈 Hospice Care 🞈 Ambulance Services 10% 10% 10% 30% 10% 10% Outpatient Therapy Services (Combined Network &  Non-Network limits) 🞈 Physician Home and Off ice Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Faci lity Limits apply to: 🞈 Cardiac Re habilitation Unlimited 🞈 Pulmonary R ehabilitation Unlimited 🞈 Phy sical Therapy: 30 visits 🞈 Occupa tional Therapy: 30 visits 🞈 Manip ulation Therapy: 30 visits 🞈 Speech therapy: 30 visits $30/$40 10% 30% 30% Accidental Dental: unlimited Copayments/Coinsurance based on setting where covered services are received 30% Behavioral Health: Mental I llness and Substance Abuse2 🞈 Inpatient Facility Services 🞈 In patient Professional Services 🞈 Physician Ho me and Office Visits (PCP/SCP) 🞈 Other Outpatient Services. Outpatient Facility @ Hospital/Alternative Care Facility, Outpatient Professional 10% 10% $30/$30 10% 30% 30% 30% 30% Huma n Organ and Tissue Transplants3 🞈 Acquisition and transplant procedures, harvest and storage. 10% 30% Covered Benefits Network Non-Network Prescription Drugs Networ k Tier structure equals 1/2/3 /4 🞈 Network R etail Pharmacies: (30-day supply) 🞈 Anthem Rx Direct Mail Service: (90-day supply) $10/$25/$50/10% max $1500 $20/$50/$100 Out of Pocket Limit: None 50%, min $30 5 Not covered Medicare Rx - Wrap Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits.

Benefit Summary. Medical/Prescription Norton City Schools Blue Access® (PPO) Covered Benefits Network Non-Network Deductible (Single/Family) $1,100/$2,200*(see wellness) $1,400/$2,800* (see wellness) Out-of-Pocket Limit (Single/Family) $1,900/$3,800* (see wellness) $2,800/$5,600* (see wellness) Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: 🞈 allergy injections (PCP and SCP) 🞈 allergy testing 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, 🞈 Non-maternity related Ultrasounds and pharmaceutical products $30/$40 $10 10% 10% 30% 30% 30% 30% Preventive Care Services Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations1, Annual diabetic eye exam, Vision and Hearing screenings 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility No copayment/coinsurance No copayment/coinsurance 30% 30% Emergency and Urgent Care Emergency Room Services 🞈 facility/other covered services (copayment waived if admitted) Urgent Care Center Services 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-maternity related Ultrasounds and pharmaceutical products 🞈 Allergy injections 🞈 Allergy testing $150 $40 10% $10 10% $150 30% 30% 30% 30% Inpatient and Outpatient Professional Services Include but are not limited to: 🞈 Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams 10% 30% Inpatient Facility Services (Network/Non-Network combined) Unlimited days except for: 🞈 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 🞈 120 days for skilled nursing facility 10% 30% Covered Benefits Network Non-Network Outpatient Surgery Hospital/Alternative Care Facility 🞈 Surgery and administration of general anesthesia 10% 30% Other Outpatient Services (Combined Network & Non- Network limits) including but not limited to: 🞈 Non Surgical Outpatient Services for example: MRIs, C-Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatient services. 🞈 Home Care Services 90 visits (excludes IV Therapy) 🞈 Durable Medical Equipment and Orthotics 🞈 Prosthetic Devices 🞈 Prosthetic Limbs 🞈 Physical Medicine Therapy Day Rehabilitation programs 🞈 Hospice Care 🞈 Ambulance Services 10% 10% 10% 30% 10% 10% Outpatient Therapy Services (Combined Network & Non-Network limits) 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility Limits apply to: 🞈 Cardiac Rehabilitation Unlimited 🞈 Pulmonary Rehabilitation Unlimited 🞈 Physical Therapy: 30 visits 🞈 Occupational Therapy: 30 visits 🞈 Manipulation Therapy: 30 visits 🞈 Speech therapy: 30 visits $30/$40 10% 30% 30% Accidental Dental: unlimited Copayments/Coinsurance based on setting where covered services are received 30% Behavioral Health: Mental Illness and Substance Abuse2 🞈 Inpatient Facility Services 🞈 Inpatient Professional Services 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services. Outpatient Facility @ Hospital/Alternative Care Facility, Outpatient Professional 10% 10% $30/$30 10% 30% 30% 30% 30% Human Organ and Tissue Transplants3 🞈 Acquisition and transplant procedures, harvest and storage. 10% 30% Covered Benefits Network Non-Network Prescription Drugs Netw1/2/3/4 ork Tier structure equals 1/2/3 /4 🞈 Network Retail Pharmacies: (30-day supply) 🞈 Anthem Rx Direct Mail Service: (90-day supply) $10/$25/$50/10% max $1500 $20/$50/$100 Out of Pocket Limit: None 50%, min $30 5 Not covered Medicare Rx - Wrap Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits.