Common use of Important Questions Answers Why This Matters Clause in Contracts

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 1,000 person / $600 2,000 family For non-participating providers: $2,000 person / $4,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $2,000 person / $4,000 family (coinsurance only, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays). For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–-of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? Appendix "D" No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 30 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 30 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 15 copay (retail) 30-day retail)/ $15 copay/prescription 30 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90-day supply (mail order prescription), 30-day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 30 copay (retail) 30-day retail)/ $60 copay/prescription copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 60 copay (retail) 30-day retail)/ $90 copay/prescription 120 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 15 copay (specialty pharmacygeneric)/$30 copay (preferred brand)/ $60 copay (non-preferred brand) 50% coinsurance deductible does not apply Not Covered Appendix "D" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 20% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care No charge Charge (emergency services)/$150 copay/visit (non-emergency services) No Charge (emergency services)/$150 copay/visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted to the hospital or the result of an accidental injury. Emergency medical transportation 20% coinsurance 20% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $30 copay/visit 40% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 20% coinsurance 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $30 copay /visit (office visit) /20% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services 20% coinsurance 40% coinsurance If you are pregnant Office visits No Charge 40% coinsurance Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Baby does not count Childbirth/delivery professional services 20% coinsurance 40% coinsurance Childbirth/delivery facility services 20% coinsurance 44 40% coinsurance Appendix "D" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care 20% coinsurance Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 20% coinsurance 20% coinsurance Limited to 120 days per year. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization required for all rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No Charge No Charge Bereavement counseling is recommendedcovered. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Appendix "D" Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Appendix "D" Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $200 individual, 0 $600 family 250 Individual/ $500 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, Individual/ $12,700 family Out-of-Network: $6,350 per individual, Family $12,700 family Individual/ $25,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus visit; deductible does not apply 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus visit; deductible does not apply 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge Charge; deductible does not apply 20% coinsurance Preauthorization is recommended for certain services. None Imaging (CT/PET scans, MRIs) No charge Charge; deductible does not apply 20% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 copay/prescription (retail) copay for retail 30-day supply; $15 copay/prescription (mail5 copay for mail order 90-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsuranceday supply; deductible does not applyapply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Preauthorization, step therapy and quantity limits may apply to select drugs. Tier 2/Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription drug program. Preferred brand brand-name drugs $20 copay/prescription (retail) 10 copay for retail 30-day supply; $60 copay/prescription (mail10 copay for mail order 90-order) Not covered Tier 3/Nonday supply; deductible does not apply In-preferred brand Network copay plus an additional 25% of the approved amount; deductible does not apply Nonpreferred brand-name drugs $30 copay/prescription (retail) 10 copay for retail 30-day supply; $90 copay/prescription (mail10 copay for mail order 90-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50day supply; deductible does not apply In-Network copay plus an additional 25% coinsurance of the approved amount; deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge Charge; deductible does not apply 20% coinsurance Preauthorization is recommended. None Physician/surgeon fees No Charge; deductible does not apply 20% coinsurance None Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) OutIn-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need immediate medical attention Emergency room care $50 copay/visit; deductible does not apply $50 copay/visit; deductible does not apply Copay waived if admitted or for an accidental injury. Emergency medical transportation No Charge; deductible does not apply No Charge; deductible does not apply Mileage limits apply Urgent care $10 copay/visit; deductible does not apply 20% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No Charge; deductible does not apply 20% coinsurance Preauthorization is required Physician/surgeon fee No Charge; deductible does not apply 20% coinsurance None If you need behavioral health services (mental health and substance use disorder) Outpatient services No Charge; deductible does not apply No Charge; deductible does not apply for mental health; 20% coinsurance for substance use disorder Your cost share may be different for services performed in an office setting Inpatient services No Charge; deductible does not apply 20% coinsurance Preauthorization is required. If you are pregnant Office visits Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply Prenatal: 20% coinsurance Postnatal: 20% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound) and depending on the type of services cost share may apply. Cost sharing does not apply for preventive services. Childbirth/delivery professional services No Charge; deductible does not apply 20% coinsurance None Childbirth/delivery facility services No Charge; deductible does not apply 20% coinsurance None If you need help recovering or have other special health needs Home health care No charge Charge; deductible does not apply No Charge; deductible does not apply Physician certification required. Rehabilitation services No Charge; deductible does not apply 20% coinsurance None Rehabilitation Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Habilitation services No Charge; deductible does not apply for Applied Behavioral Analysis; No Charge; deductible does not apply for Physical, Speech and Occupational Therapy No Charge; deductible does not apply for Applied Behavioral Analysis; 20% coinsurance 20% coinsurance Includes for Physical, Speech and Occupational and Speech TherapyTherapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Charge; deductible does not apply No Charge; deductible does not apply Preauthorization is recommendedrequired. Custodial Care is not covered. Limited to 120 days per member per calendar year Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo Charge; deductible does not apply No Charge; deductible does not apply Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge; deductible does not apply No Charge; deductible does not apply Physician certification required. Visit limits apply. If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not covered Not covered None Children’s glasses Not covered Not covered None Children’s dental check-check- up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture treatment • Cosmetic surgery • Dental care (Adult) • Dental check-up, child Hearing aids • Glasses, child Infertility treatment • Long-Long term care • Routine eye care (Adult) • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage Coverage provided outside the United States. Contact Customer Service for more information. See xxxx://xxxxxxxx.xxxx.xxx • Non-emergency care when traveling outside the U.S • Private-duty nursing • Routine eye care (Adult)Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 250 person / $600 500 family For non-participating providers: $500 person / $1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $500 person / $1,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Appendix "E" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 7 copay (retail) 30-day retail)/ $15 copay/prescription 14 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 35 copay (retail) 30-day retail)/ $60 copay/prescription 70 copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 70 copay (retail) 30-day retail)/ $90 copay/prescription 140 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 7 copay (specialty pharmacygeneric)/ $35 copay (preferred brand) 50% coinsurance deductible does not apply /$70 copay (non-preferred brand) 50 Not Covered Appendix "E" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2010% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 10% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care No Charge (emergency services)/$50 copay/visit (non-emergency services) No Charge (emergency services)/$50 copay/visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is recommendedwaived if admitted to the hospital or the result of an accidental injury. Emergency medical transportation 10% coinsurance 10% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $20 copay/visit 40% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 10% coinsurance 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $20 copay /visit (office visit) /10% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services 10% coinsurance 40% coinsurance If you are pregnant Office visits No Charge 40% coinsurance Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. Childbirth/delivery professional services 10% coinsurance 40% coinsurance Childbirth/delivery facility services 10% coinsurance 40% coinsurance Appendix "E" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care 10% coinsurance Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 10% coinsurance 10% coinsurance Limited to 120 days per year. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 10% coinsurance 10% coinsurance Preauthorization required for all rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No Charge No Charge Bereavement counseling is covered. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Appendix "E" Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Appendix "E" Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 1,000 person / $600 2,000 family For non-participating providers: $2,000 person / $4,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $2,000 person / $4,000 family (coinsurance only, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays). For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–-of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? Appendix "G" No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 30 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 30 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 15 copay (retail) 30-day retail)/ $15 copay/prescription 30 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90-day supply (mail order prescription), 30-day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 30 copay (retail) 30-day retail)/ $60 copay/prescription copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 60 copay (retail) 30-day retail)/ $90 copay/prescription 120 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 15 copay (specialty pharmacygeneric)/$30 copay (preferred brand)/ $60 copay (non-preferred brand) 50% coinsurance deductible does not apply Not Covered Appendix "G" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 20% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care No charge Charge (emergency services)/$150 copay/visit (non-emergency services) No Charge (emergency services)/$150 copay/visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted to the hospital or the result of an accidental injury. Emergency medical transportation 20% coinsurance 20% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $30 copay/visit 40% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 20% coinsurance 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $30 copay /visit (office visit) /20% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services 20% coinsurance 40% coinsurance If you are pregnant Office visits No Charge 40% coinsurance Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Baby does not count Childbirth/delivery professional services 20% coinsurance 40% coinsurance Childbirth/delivery facility services 20% coinsurance 38 40% coinsurance Appendix "G" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care 20% coinsurance Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 20% coinsurance 20% coinsurance Limited to 120 days per year. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization required for all rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No Charge No Charge Bereavement counseling is recommendedcovered. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Appendix "G" Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Appendix "G" Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 500 person / $600 1,000 family For non-participating providers: $1,000 person / $2,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $1,500 person / $3,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)Appendix "C" 23

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. received You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay20% coinsurance/prescription (retail) $15 copay/prescription (retail & mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay20% coinsurance/prescription (retail) $60 copay/prescription (retail & mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay20% coinsurance/prescription (retail) $90 copay/prescription (retail & mail-order) Not covered Tier 4/Specialty drugs $30 copay20% coinsurance/prescription (specialty pharmacypharmacy only) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 75 copay/visit $100 75 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge admitted. Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/office visit $10 copay/office visit plus20plus 20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20plus 20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 15 copay/office visit $10 15 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. received You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay20% coinsurance/prescription (retail) $15 copay/prescription (retail & mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay20% coinsurance/prescription (retail) $60 copay/prescription (retail & mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay20% coinsurance/prescription (retail) $90 copay/prescription (retail & mail-order) Not covered Tier 4/Specialty drugs $30 copay20% coinsurance/prescription (specialty pharmacypharmacy only) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 75 copay/visit $100 75 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge admitted. Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 20 copay/urgent care center visit $10 20 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 15 copay/office visit No charge /outpatient services $10 15 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 20 copay/office visit plus20$20 copay/visit plus 20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Childbirth/delivery facility services No charge 20% coinsurance If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge charge for services to treat autism spectrum disorder and preauthorization is not required required. Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20plus 20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. What is the overall deductible? For In Network providers $250 for an individual plan/$500 for a family plan. For Out-ofof Network providers $1000 for an individual plan/$2000 for a family plan. *Effective January 1, 2021 the annual in-Network: network deductible shall be $200 individual, 500 for an individual plan and $600 1000 for a family plan. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room careDoesn't apply to preventive services, emergency medical transportation services with a fixed dollar copay, prescription drugs and some specialty drugs diagnostic testing. This plan covers some items and services even if you haven’t n't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost- sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/ preventive-care-benefits/. Are there other deductibles for specific services? No. No You don’t n't have to meet deductibles deductible for specific services. What is the out-of-pocket limit for this plan? In-Network: For In Network providers $6,350 individual, $12,700 750 for an individual plan/$1500 for a family plan. For Out-of-Network: Network providers $6,350 per individual, $12,700 3000 for an individual plan/$6000 for a family plan. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to a meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, billed charges and health care this plan doesn’t n't cover. Even though you pay these expenses, they don’t n't count toward the out–-of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-out- of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s 's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? specialist No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will you will Pay Limitations, Exceptions, & Other Important Information If you visit a health care provider’s office or clinic In Network Provider provider (You will pay the least) Out-of-Network Provider provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 15 copay/office ; deductible does not apply per visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 25 copay/office ; deductible does not apply per visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per yearyear Preventive Care Screening Immunization No Charge; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus deductible does not apply 20% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx : If you have a test Diagnostic test (x-ray, blood work) No charge Charge; deductible does not apply 20% coinsurance Preauthorization is recommended for certain services. services Imaging (CT/PET scans, MRIs) No charge Charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic 1 generally low-cost generic drugs $5 copay/; deductible does not apply per prescription (retail) $15 10 copay/; deductible does not apply per prescription (mail-order) Not covered Covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. apply Tier 2/Preferred 2 generally high cost generic and preferred brand name drugs $20 15 copay/; deductible does not apply per prescription (retail) $30 copay; deductible does not apply per prescription (mail-order) Not Covered Tier 3 non-preferred brand name drugs $30 copay; deductible does not apply per prescription (retail) $60 copay/; deductible does not apply per prescription (mail-order) Not covered Covered Tier 3/Non-preferred brand 4 specialty prescription drugs $30 copay/; deductible does not apply per prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance coinsurance; deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge Charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Deductible does not apply. Physician/surgeon fees No charge Charge 20% coinsurance None Deductible does not apply If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply per visit $100 copay; deductible does not apply per visit Emergency room: Copay waived if admitted admitted; Air/Water Ambulance: No charge Charge Urgent Carecare: Visit Applies to the visit only; . If additional services received are subject to provided additional out-of-out of pocket costs. costs would apply based on services received; Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply per trip $50 copay; deductible does not apply per trip Urgent care $10 50 copay/; deductible does not apply per urgent care center visit $10 50 copay/; deductible does not apply per urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge Charge 20% coinsurance 45 45-day limit at an inpatient rehabilitation facility; Preauthorization is recommended Deductible does not apply Physician/surgeon fees fee No charge Charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services Inpatient services $10 15 copay; deductible does not apply/office visit No charge /outpatient Charge for outpatient services $10 copay/No Charge 20% coinsurance/ office visit plus 20% coinsurance for outpatient services 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 25 copay/; deductible does not apply per visit $10 copay/office visit plus2020% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge Charge 20% coinsurance Childbirth/delivery facility services No charge Charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge Charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy; limited to 30 visits each (combined for in and out of network). Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is Deductible does not required apply Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge Charge 20% coinsurance Preauthorization is recommended. Custodial Care care is not covered. ; Preauthorization is recommended Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Deductible does not apply Hospice services service No charge Charge 20% coinsurance Preauthorization is recommended. None If your child needs dental or eye care Children’s eye exam $10 25 copay/office ; deductible does not apply per visit $10 copay/office visit plus2020% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Covered Not covered Covered None Children’s dental check-check- up Not covered Covered Not covered Covered None Excluded Services & and Other Covered Services: Services Your your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Telemedicine Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-$3000 Single (Paramount Ohio HMO Network: .) $200 individual, $600 family 6000 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles otherdeductibles for specific services? No. No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-$3000 Single (Paramount Ohio HMO Network: .) $6,350 individual, $12,700 family Out-of-6000 Family(Paramount Ohio HMO Network: $6,350 per individual, $12,700 family .) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-out- of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in includedin the out-of-pocket limit? Premiums, balance-billing charges, Premiums and health care this plan doesn’t n't cover. Even though you pay these expenses, they don’t count toward the out–of–– pocket limit. Will you pay less if you ifyou use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network providersParamount Ohio HMO Network Providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s 's charge and what your plan pays (a balance billingbill). Be aware, aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral areferral to see a specialist? No. No You can see the specialist you choose without a referral. HSA All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s 's office or clinic Primary care Care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None No charge. Not covered. –––––––––––none––––––––––– Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits No charge. Not covered. –––––––––––none––––––––––– Preventive care/screening/ immunization screening /immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services receivedcharge. Not covered. You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxxxxxxx.xxxxxxxxxxxxxxxxxxx.xxx/Xxxxxxxxx- PharmacyResources-CommercialDrugBenefits Prescription Drug Coverage Not Covered By Paramount. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not applyCovered By Paramount. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply Covered By Paramount. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommendedcharge. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costscharge. Payable under HMO network of benefits. –––––––––––none––––––––––– Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended charge. Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need mental health, behavioral health, ,or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Inpatient services No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on No charge. Not covered. Cost sharing does not apply for preventive services. 55 *For more information about limitations and exceptions, see the type of services, coinsurance may applyplan or policy document at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance HSA HSA Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you are pregnant Childbirth/delivery professional services No charge. Not covered. –––––––––––none––––––––––– Childbirth/delivery facility services No charge. Not covered. –––––––––––none––––––––––– If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None charge. Not covered. In Lieu of Hospitalization Rehabilitation services 20% coinsurance 20% coinsurance Includes PhysicalNo charge. Not covered. Outpatient physical, Occupational occupational and Speech Therapyspeech therapy limited to 30 visits combined. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance No charge. Not covered. Outpatient physical, occupational and speech therapy limited to 30 visits combined. Skilled nursing care No charge 20% coinsurance Preauthorization is recommendedcharge. Custodial Care is not Not covered. Unliimited days. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo charge. Not covered. Subject to Medicare part B Guidelines. Hospice services No charge 20% coinsurance Preauthorization is recommendedcharge. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Children’s 's eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance No charge. Not covered. Limited to one (1) routine eye vision exam per yearevery twelve (12) months. Children’s 's glasses Not covered covered. Not covered None covered. –––––––––––none––––––––––– Children’s 's dental check-up Not covered covered. Not covered None covered. –––––––––––none––––––––––– Excluded Services & Other Covered Services: HSA Services Your Plan Generally Does NOT Cover cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental checkPrivate-up, child duty nursing • Glasses, child Bariatric Surgery • Long-term care • Routine foot care unless to treat a systemic condition • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t n't a complete list. Please see check your plan document.) • Bariatric Surgery . • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatment (Excludes infertility drugs) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration, 1-866-444-EBSA (3272), xxx.xxx.xxx/xxxx/xxxxxxxxxxxx

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of 0 See the Common Medical Events chart below for your costs from providers up to the deductible amount before for services this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductiblecovers. Are there services covered before you meet your deductible? YesNo. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met You will have to meet the deductible amount. But a copayment or coinsurance may applybefore the plan pays for any services. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network$1,500 Individual/$3,000 Family Prescription drug expense limit: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family 500 Individual/$1,500 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-of- pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxx.xxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network participating providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral Referral to see a specialist? NoYes. You can This plan will pay some or all of the costs to see a specialist for covered services but only if you have a Referral before you see the specialist you choose without a referralspecialist. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 30 copay/office visit $10 copay/office visit plus 20% coinsurance None Not Covered Services or supplies that are not ordered by your Primary Care Physician or Women’s Principal Health Care Provider, except emergency and routine vision exams, are not covered. Specialist visit $10 50 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Not Covered Referral required. Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge Not Covered You may have to pay for services that aren’t preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain servicesCharge Not Covered Referral required. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Charge Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommendedCovered Referral required. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxxxxx.xxx. Generic drugs $10 copay/prescription (retail) $20 copay/prescription (mail order) Not Covered Dispensing limit may apply to certain drugs. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Certain women’s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. 30-day retail/90-day mail. RX Out-of-Pocket Expense Limit: $500 Individual/$1,500 Family. Preferred brand drugs $40 copay/prescription (retail) $80 copay/prescription (mail order) Not Covered Non-preferred brand drugs $60 copay/prescription (retail) $120 copay/prescription (mail order) Not Covered Specialty drugs Applicable copay Not Covered Coverage based on group policy. Prior authorization may be required. Specialty retail limited to a 30-day supply. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge Not Covered Referral required. Physician/surgeon fees No charge 20% coinsurance None Charge Not Covered Referral required. If you need immediate medical attention Emergency room care $100 250 copay/visit $100 250 copay/visit; deductible does not apply Emergency room: visit Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costsadmitted. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply No Charge No Charge Ground transportation only. Urgent care $10 30 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance Not Covered Must be affiliated with member’s chosen medical group or referral required. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended $250 copay/admission Not Covered Referral required. Physician/surgeon fees No charge 20% coinsurance None Charge Not Covered Referral required. If you need mental health, behavioral health, or substance abuse services Outpatient services $10 30 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicesNot Covered Unlimited visits. Referral required. Inpatient services No charge 20% coinsurance $250 copay/admission Not Covered Unlimited days. Referral required. If you are pregnant Office visits $10 30 copay/visit $10 copay/office Not Covered Copay applies for the 1st prenatal visit plus20% coinsurance only. Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance a copayment may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Charge Not Covered Childbirth/delivery facility services $250 copay/admission Not Covered Referral required. If you need help recovering or have other special health needs Home health care No charge 20% coinsurance Charge Not Covered Referral required. Rehabilitation services $30 copay/visit Not Covered 60 visits combined for all therapies. Referral required. Habilitation services $30 copay/visit Not Covered Skilled nursing care $250 copay/admission Not Covered Excludes custodial care. Referral required. Durable medical equipment No Charge Not Covered Referral required. Benefits are limited to items used to serve a medical purpose. Durable Medical Equipment benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice services No Charge Not Covered Inpatient copay may apply. Referral required. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance No Charge Not Covered Limited to one routine eye exam per yearevery 12 months at participating providers. Children’s glasses Not covered Covered Not covered Covered None Children’s dental check-up Not covered Covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)None

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $100 Individual/ $200 individual, Family $600 family 250 Individual/ $500 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, Individual/ $12,700 family Out-of-Network: $6,350 per individual, Family $12,700 family Individual/ $25,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 30% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 30% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 30% coinsurance None Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 30% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 copay/prescription (retail) 10 copay for retail 30-day supply; $15 copay/prescription (mail10 copay for retail or mail order 90-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsuranceday supply; deductible does not applyapply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Preauthorization, step therapy and quantity limits may apply to select drugs. Tier 2/Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription drug program. Preferred brand brand-name drugs $20 copay/prescription (retail) copay for retail 30-day supply; $60 copay/prescription (mail20 copay for retail or mail order 90-order) Not covered Tier 3/Nonday supply; deductible does not apply In-preferred brand Network copay plus an additional 25% of the approved amount; deductible does not apply Nonpreferred brand-name drugs $30 copay/prescription (retail) 20 copay for retail 30-day supply; $90 copay/prescription (mail20 copay for retail or mail order 90-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50day supply; deductible does not apply In-Network copay plus an additional 25% coinsurance of the approved amount; deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2010% coinsurance Preauthorization is recommended30% coinsurance None Physician/surgeon fees 10% coinsurance 30% coinsurance None If you need immediate medical attention Emergency room care $50 copay/visit; deductible does not apply $50 copay/visit; deductible does not apply Copay waived if admitted or for an accidental injury. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20Emergency medical transportation 10% coinsurance None If you need immediate medical attention Emergency room 10% coinsurance Mileage limits apply Urgent care $100 copay/visit $100 10 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 2030% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No charge 2010% coinsurance 45 day limit at an inpatient rehabilitation facility; 30% coinsurance Preauthorization is recommended required Physician/surgeon fees No charge 20fee 10% coinsurance 30% coinsurance None If you need behavioral health services (mental health and substance use disorder) Outpatient services 10% coinsurance 10% coinsurance for mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20; 30% coinsurance 20for substance use disorder Your cost share may be different for services performed in an office setting Inpatient services 10% coinsurance /outpatient services 30% coinsurance Preauthorization is recommended for certain servicesrequired. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply Prenatal: 30% coinsurance Depending on the type of services, Postnatal: 30% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)) and depending on the type of services cost share may apply. Preauthorization is recommendedCost sharing does not apply for preventive services. Childbirth/delivery professional services No charge 2010% coinsurance 30% coinsurance None Childbirth/delivery facility services No charge 2010% coinsurance 30% coinsurance None If you need help recovering or have other special health needs Home health care 10% coinsurance 10% coinsurance Physician certification required. Rehabilitation services 10% coinsurance 30% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services 10% coinsurance for Applied Behavioral Analysis; 10% coinsurance for Physical, Speech and Occupational Therapy 10% coinsurance for Applied Behavioral Analysis; 30% coinsurance for Physical, Speech and Occupational Therapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Skilled nursing care 10% coinsurance 10% coinsurance Preauthorization is required. Limited to 120 days per member per calendar year Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 2010% coinsurance 2010% coinsurance Preauthorization is recommended for certain servicesExcludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge; deductible does not apply No Charge; deductible does not apply Physician certification required. Visit limits apply. If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not covered Not covered None Children’s glasses Not covered Not covered None Children’s dental check-check- up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture treatment • Cosmetic surgery • Dental care (Adult) • Dental check-up, child Hearing aids • Glasses, child Infertility treatment • Long-Long term care • Routine eye care (Adult) • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage Coverage provided outside the United States. Contact Customer Service for more information. See xxxx://xxxxxxxx.xxxx.xxx • Non-emergency care when traveling outside the U.S • Private-duty nursing • Routine eye care (Adult)Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 250 person / $600 500 family For non-participating providers: $500 person / $1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $500 person / $1,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Appendix "F" Generic drugs $5 copay/prescription 7 copay (retail) 30-day retail)/ $15 copay/prescription 14 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 35 copay (retail) 30-day retail)/ $60 copay/prescription 70 copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 70 copay (retail) 30-day retail)/ $90 copay/prescription 140 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 7 copay (specialty pharmacygeneric)/ $35 copay (preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee /$70 copay (e.g., ambulatory surgery centernon-preferred brand) No charge 20% coinsurance Preauthorization is recommended. Page 64 Not Covered Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 2010% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$50 copay/visit $100 (non-emergency services) No Charge (emergency services)/$50 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 10% coinsurance 10% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 20 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 2010% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 2010% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/20 copay /visit (office visit No charge /outpatient services $10 copay/office visit plus 20visit) /10% coinsurance 20(all other outpatient) 40% coinsurance /outpatient services Includes telemedicine consultations by providers other than Teladoc. Preauthorization is recommended required for certain inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services No charge 2010% coinsurance 40% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 2010% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 2010% coinsurance 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 2010% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services 20No Charge (services related to autism)/10% coinsurance 20(all other services) 40% coinsurance Includes Physical, Occupational and Speech Therapyspeech & occupational therapy limited to a combined maximum of 60 visits per year. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. Habilitation services No Charge for (services related to treat autism spectrum disorder and preauthorization is not required Habilitation services 20autism)/10% coinsurance 20(all other services) 40% coinsurance ----------------none---------------- Skilled nursing care No charge 2010% coinsurance 10% coinsurance Limited to 120 days per year. Preauthorization is recommendedrequired. Custodial Care is not coveredIf you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 2010% coinsurance 2010% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 250 person / $600 500 family For non-participating providers: $500 person / $1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $500 person / $1,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Appendix "E" Generic drugs $5 copay/prescription 7 copay (retail) 30-day retail)/ $15 copay/prescription 14 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 35 copay (retail) 30-day retail)/ $60 copay/prescription 70 copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 70 copay (retail) 30-day retail)/ $90 copay/prescription 140 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 7 copay (specialty pharmacygeneric)/ $35 copay (preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee /$70 copay (e.g., ambulatory surgery centernon-preferred brand) No charge 20% coinsurance Preauthorization is recommended. 38 Not Covered Appendix "E" 39 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 2010% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$50 copay/visit $100 (non-emergency services) No Charge (emergency services)/$50 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 10% coinsurance 10% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 20 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 2010% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 2010% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/20 copay /visit (office visit No charge /outpatient services $10 copay/office visit plus 20visit) /10% coinsurance 20(all other outpatient) 40% coinsurance /outpatient services Includes telemedicine consultations by providers other than Teladoc. Preauthorization is recommended required for certain inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services No charge 2010% coinsurance 40% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 2010% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 2010% coinsurance 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 2010% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services 20No Charge (services related to autism)/10% coinsurance 20(all other services) 40% coinsurance Includes Physical, Occupational and Speech Therapyspeech & occupational therapy limited to a combined maximum of 60 visits per year. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. Habilitation services No Charge for (services related to treat autism spectrum disorder and preauthorization is not required Habilitation services 20autism)/10% coinsurance 20(all other services) 40% coinsurance ----------------none---------------- Skilled nursing care No charge 2010% coinsurance 10% coinsurance Limited to 120 days per year. Preauthorization is recommendedrequired. Custodial Care is not coveredIf you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 2010% coinsurance 2010% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adultfor morbid obesity only)

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $200 individual, 1,400 Individual/ $600 family 2,800 Family $2,800 Individual/ $5,600 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the planpolicy, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductibledeductible must be met before the plan begins to pay. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, 2,250 Individual/ $12,700 family Out-of-Network: 4,500 Family $6,350 per individual, 3,500 Individual/ $12,700 family 7,000 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been must be met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus No Charge 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus No Charge 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge Charge 20% coinsurance Preauthorization is recommended for certain services. None Imaging (CT/PET scans, MRIs) No charge Charge 20% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/NonNone Preferred brand-preferred brand name drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty Not covered Nonpreferred brand-name drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply Not covered Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge Charge 20% coinsurance None Physician/surgeon fees No Charge 20% coinsurance None If you need immediate medical attention Emergency room care No Charge No Charge None Emergency medical transportation No Charge No Charge Mileage limits apply Urgent care No Charge No Charge None If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance Preauthorization is recommended. required Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees fee No charge Charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visitbehavioral health services (mental health and substance use disorder) Outpatient services No Charge No Charge for mental health; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or for substance abuse services use disorder Outpatient services $10 copay/are covered at participating facility only. Your cost share may be different for services performed in an office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicessetting. Inpatient services No charge Charge 20% coinsurance Preauthorization is required. If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20Prenatal: No Charge; deductible does not apply Postnatal: No Charge Prenatal: 20% coinsurance Depending on the type of services, Postnatal: 20% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)) and depending on the type of services cost share may apply. Preauthorization is recommendedCost sharing does not apply for preventive services. Childbirth/delivery professional services No charge Charge 20% coinsurance None Childbirth/delivery facility services No charge Charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) None If you need help recovering or have other special health needs Home health care No charge Charge No Charge Physician certification required. Rehabilitation services No Charge 20% coinsurance None Rehabilitation Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services No Charge for Applied Behavioral Analysis No Charge for Physical, Speech and Occupational Therapy No Charge for Applied Behavioral Analysis 20% coinsurance 20% coinsurance Includes for Physical, Speech and Occupational and Speech TherapyTherapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Charge No Charge Preauthorization is recommendedrequired. Custodial Care is not covered. Limited to 90 days per member per calendar year Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo Charge No Charge Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge No Charge Physician certification required. Visit limits apply. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)None

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-$3000 Single (Paramount Ohio HMO Network: .) $200 individual, $600 family 6000 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles otherdeductibles for specific services? No. No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-$3000 Single (Paramount Ohio HMO Network: .) $6,350 individual, $12,700 family Out-of-6000 Family(Paramount Ohio HMO Network: $6,350 per individual, $12,700 family .) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-out- of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in includedin the out-of-pocket limit? Premiums, balance-billing charges, Premiums and health care this plan doesn’t n't cover. Even though you pay these expenses, they don’t count toward the out–of–– pocket limit. Will you pay less if you ifyou use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network providersParamount Ohio HMO Network Providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s 's charge and what your plan pays (a balance billingbill). Be aware, aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral areferral to see a specialist? No. No You can see the specialist you choose without a referral. HSA All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s 's office or clinic Primary care Care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None No charge. Not covered. –––––––––––none––––––––––– Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits No charge. Not covered. –––––––––––none––––––––––– Preventive care/screening/ immunization screening /immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services receivedcharge. Not covered. You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxxxxxxx.xxxxxxxxxxxxxxxxxxx.xxx/Xxxxxxxxx- PharmacyResources-CommercialDrugBenefits Prescription Drug Coverage Not Covered By Paramount. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not applyCovered By Paramount. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply Covered By Paramount. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommendedcharge. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costscharge. Payable under HMO network of benefits. –––––––––––none––––––––––– Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended charge. Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Inpatient services No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on No charge. Not covered. Cost sharing does not apply for preventive services. 44 *For more information about limitations and exceptions, see the type of services, coinsurance may applyplan or policy document at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance HSA HSA Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you are pregnant Childbirth/delivery professional services No charge. Not covered. –––––––––––none––––––––––– Childbirth/delivery facility services No charge. Not covered. –––––––––––none––––––––––– If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None charge. Not covered. In Lieu of Hospitalization Rehabilitation services 20% coinsurance 20% coinsurance Includes PhysicalNo charge. Not covered. Outpatient physical, Occupational occupational and Speech Therapyspeech therapy limited to 30 visits combined. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance No charge. Not covered. Outpatient physical, occupational and speech therapy limited to 30 visits combined. Skilled nursing care No charge 20% coinsurance Preauthorization is recommendedcharge. Custodial Care is not Not covered. Unliimited days. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo charge. Not covered. Subject to Medicare part B Guidelines. Hospice services No charge 20% coinsurance Preauthorization is recommendedcharge. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Children’s 's eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance No charge. Not covered. Limited to one (1) routine eye vision exam per yearevery twelve (12) months. Children’s 's glasses Not covered covered. Not covered None covered. –––––––––––none––––––––––– Children’s 's dental check-up Not covered covered. Not covered None covered. –––––––––––none––––––––––– Excluded Services & Other Covered Services: HSA Services Your Plan Generally Does NOT Cover cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental checkPrivate-up, child duty nursing • Glasses, child Bariatric Surgery • Long-term care • Routine foot care unless to treat a systemic condition • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t n't a complete list. Please see check your plan document.) • Bariatric Surgery . • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatment (Excludes infertility drugs) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration, 1-866-444-EBSA (3272), xxx.xxx.xxx/xxxx/xxxxxxxxxxxx

Important Questions Answers Why This Matters. What is the overall deductible? For In-Network: $750 Individual/$2,250 Family For Out-of-Network: $200 individual, $600 family 1,500 Individual/$4,500 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room Certain preventive care, services that charge a copay, prescription drugs, and emergency medical transportation and some specialty drugs room services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx- care-benefits/. Are there other deductibles for specific services? NoYes. $300 deductible for Out-of-Network hospital admission. There are no other specific deductibles. You don’t have must pay all of the costs for these services up to meet deductibles the specific deductible amount before this plan begins to pay for specific these services. What is the out-of-pocket limit for this plan? For In-Network: $6,350 individual, $12,700 family 2,750 Individual/$8,250 Family For Out-of-Network: $6,350 per individual, 5,500 Individual/$14,250 Family Prescription drug expense limit: $12,700 family 500 Individual/$1,500 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–-of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxx.xxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 30 copay/office visit; deductible does not apply 40% coinsurance Virtual Visits: $30/visit; deductible does not apply. See your benefit booklet* for details. Specialist visit $10 50 copay/office visit plus 20visit; deductible does not apply 40% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge; deductible does not apply 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance 40% coinsurance Preauthorization is recommended may be required; see your benefit booklet* for certain servicesdetails. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 5040% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxxxxx.xxx Generic drugs $10 copay/prescription (retail) $20 copay/prescription (mail order); deductible does not apply $10 copay/prescription (retail); deductible does not apply 30-day supply at Retail 90-day supply at Mail Order Rx Out-of-Pocket Expense Limit: $500 Individual/$1,500 Family For Out-of-Network drug provider, you are responsible for 50% of the eligible amount after the copayment. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Certain women’s preventive services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. Preferred brand drugs $40 copay/prescription (retail) $80 copay/prescription (mail order); deductible does not apply $40 copay/prescription (retail); deductible does not apply Non-preferred brand drugs $60 copay/prescription (retail) $120 copay/prescription (mail order) deductible does not apply $60 copay/prescription (retail); deductible does not apply Specialty drugs $60 copay/prescription (retail); deductible does not apply Not Covered Specialty drug coverage based on group policy. Prior authorization may be required. Specialty retail limited to a 30-day supply. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization may be required. Physician/surgeon fees No charge 20% coinsurance 40% coinsurance None Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need immediate medical attention Emergency room care $100 copay/visit $100 250 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 250 copay/trip $50 copay/tripvisit; deductible does not apply Copay waived if admitted. Emergency medical transportation 20% coinsurance 20% coinsurance Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details. Urgent care $10 30 copay/urgent care center visit $10 copay/urgent care center visit plus 20visit; deductible does not apply 40% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance $300 deductible per admission Out-of- Network providers. Preauthorization is recommended required. Physician/surgeon fees No charge 20% coinsurance 40% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 30 copay/office visit No charge /outpatient services $10 copay/office visit plus visit; deductible does not apply; 20% coinsurance for other outpatient services 40% coinsurance PCP copay applies to psychotherapy office visit only. Preauthorization may be required; see your benefit booklet* for details. Virtual Visits: $30/visit; deductible does not apply. See your benefit booklet* for details. Inpatient services 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 2040% coinsurance $300 deductible per admission Out-of- Network providers. Preauthorization required. If you are pregnant Office visits $10 30 PCP/$50 SPC copay/visit $10 copay/office visit plus20visit; deductible does not apply 40% coinsurance Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 20% coinsurance 40% coinsurance $300 deductible per admission Out-of-Network providers. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None 40% coinsurance Preauthorization may be required. Rehabilitation services 20% coinsurance 2040% coinsurance Includes Physical, Occupational and Speech TherapyPreauthorization may be required. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 2040% coinsurance Skilled nursing care No charge 20% coinsurance 40% coinsurance $300 deductible per admission Out-of-Network providers. Preauthorization is recommended. Custodial Care is not coveredmay be required. Durable medical equipment 20% coinsurance 40% coinsurance Benefits are limited to items used to serve a medical purpose. Durable Medical Equipment benefits are provided for both purchase and rental equipment (up to the purchase price). Preauthorization may be required. Hospice services 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 2040% coinsurance $300 deductible per admission Out-of-Network providers. Preauthorization is recommendedmay be required. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered None Children’s glasses Not covered Covered Not covered Covered None Children’s dental check-up Not covered Covered Not covered Covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-Long term care • Routine eye care (Adult) • Routine foot care unless to treat a systemic condition (with the exception of person with diagnosis of diabetes) • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery • Chiropractic care (Chiropractic and Osteopathic manipulation limited to 15 visits per calendar year) • Cosmetic surgery (only for correcting congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases) • Hearing aids for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months) • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. See xxx.xxxxxx.xxx • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine eye care (Adult)with the exception of inpatient private duty nursing) (unlimited visits per calendar year) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at 0-000-000-0000, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $200 individual, 500 Individual/ $600 family 1,000 Family $1,000 Individual/ $2,000 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, Individual/ $12,700 family Out-of-Network: $6,350 per individual, Family $12,700 family Individual/ $25,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 30 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 40% coinsurance None Specialist visit $10 30 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 40% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance None Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 10 copay/prescription (retail) $15 copay/prescription (mailfor retail 30-order) Not covered No charge for certain preventive drugsday supply; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/for retail or mail order 90-day supply; deductible does not apply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Preauthorization, step therapy and quantity limits may apply to select drugs. Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription (maildrug program. Preferred brand-order) Not covered Tier 3/Non-preferred brand name drugs $30 copay/prescription (retail) for retail 30-day supply; $90 60 copay/prescription (mailfor retail or mail order 90-order) Not covered Tier 4/Specialty day supply; deductible does not apply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Nonpreferred brand-name drugs $30 60 copay/prescription (specialty pharmacy) 50for retail 30-day supply; $120 copay/prescription for retail or mail order 90-day supply; deductible does not apply In-Network copay plus an additional 25% coinsurance of the approved amount; deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. 40% coinsurance None Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance 40% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 150 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 150 copay/trip $50 copay/tripvisit; deductible does not apply Copay waived if admitted or for an accidental injury. Emergency medical transportation 20% coinsurance 20% coinsurance Mileage limits apply Urgent care $10 30 copay/urgent care center visit $10 copay/urgent care center visit plus 20visit; deductible does not apply 40% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required Physician/surgeon fees No charge fee 20% coinsurance 40% coinsurance None If you need behavioral health services (mental health, behavioral health, or health and substance abuse services use disorder) Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient for mental health; 40% coinsurance for substance use disorder Your cost share may be different for services Preauthorization is recommended for certain services. performed in an office setting Inpatient services No charge 20% coinsurance 40% coinsurance Preauthorization is required. If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply Prenatal: 40% coinsurance Depending on the type of services, Postnatal: 40% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)) and depending on the type of services cost share may apply. Preauthorization is recommendedCost sharing does not apply for preventive services. Childbirth/delivery professional services No charge 20% coinsurance 40% coinsurance None Childbirth/delivery facility services No charge 20% coinsurance 40% coinsurance None If you need help recovering or have other special health needs Home health care 20% coinsurance 20% coinsurance Physician certification required. Rehabilitation services $30 copay/visit; deductible does not apply 40% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services 20% coinsurance for Applied Behavioral Analysis; 20% coinsurance for Physical, Speech and Occupational Therapy 20% coinsurance for Applied Behavioral Analysis; 40% coinsurance for Physical, Speech and Occupational Therapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health Skilled nursing care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommendedrequired. Custodial Care is not covered. Limited to 120 days per member per calendar year Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesExcludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge; deductible does not apply No Charge; deductible does not apply Physician certification required. Visit limits apply. If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)None

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $200 individual, 0 $600 family 250 Individual/ $500 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, 7,350 Individual/ $12,700 family Out-of-Network: 14,700 Family $6,350 per individual, 14,700 Individual/ $12,700 family 29,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus visit; deductible does not apply 20% coinsurance None Specialist visit $10 20 copay/office visit $10 copay/office visit plus visit; deductible does not apply 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge Charge; deductible does not apply 20% coinsurance Preauthorization is recommended for certain services. None Imaging (CT/PET scans, MRIs) No charge Charge; deductible does not apply 20% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/NonNone Preferred brand-preferred brand name drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty Not covered Nonpreferred brand-name drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply Not covered Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge Charge; deductible does not apply 20% coinsurance Preauthorization is recommendedNone Physician/surgeon fees No Charge; deductible does not apply 20% coinsurance None If you need immediate medical attention Emergency room care $50 copay/visit; deductible does not apply $50 copay/visit; deductible does not apply Copay waived if admitted or for an accidental injury. Emergency medical transportation No Charge; deductible does not apply No Charge; deductible does not apply Mileage limits apply Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room Urgent care $100 copay/visit $100 20 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 20 copay/trip $50 copay/tripvisit; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No charge Charge; deductible does not apply 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended required Physician/surgeon fees fee No charge Charge; deductible does not apply 20% coinsurance None If you need behavioral health services (mental health and substance use disorder) Outpatient services No Charge; deductible does not apply No Charge; deductible does not apply for mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus ; 20% coinsurance for substance use disorder Your cost share may be different for services performed in an office setting Inpatient services No Charge; deductible does not apply 20% coinsurance /outpatient services Preauthorization is recommended for certain servicesrequired. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply Prenatal: 20% coinsurance Depending on the type of services, Postnatal: 20% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)) and depending on the type of services cost share may apply. Preauthorization is recommendedCost sharing does not apply for preventive services. Childbirth/delivery professional services No charge Charge; deductible does not apply 20% coinsurance None Childbirth/delivery facility services No charge Charge; deductible does not apply 20% coinsurance None If you need help recovering or have other special health needs Home health care No Charge; deductible does not apply No Charge; deductible does not apply Physician certification required. Rehabilitation services No Charge; deductible does not apply 20% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services No Charge; deductible does not apply for Applied Behavioral Analysis; No Charge; deductible does not apply for Physical, Speech and Occupational Therapy No Charge; deductible does not apply for Applied Behavioral Analysis; 20% coinsurance for Physical, Speech and Occupational Therapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Charge; deductible does not apply No Charge; deductible does not apply Preauthorization is recommendedrequired. Custodial Care is not covered. Limited to 120 days per member per calendar year Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo Charge; deductible does not apply No Charge; deductible does not apply Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge; deductible does not apply No Charge; deductible does not apply Physician certification required. Visit limits apply. If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not covered Not covered None Children’s glasses Not covered Not covered None Children’s dental check-check- up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture treatment • Cosmetic surgery • Dental care (Adult) • Dental check-up, child Infertility treatment • Glasses, child • Long-Long term care • Routine eye care (Adult) • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage Coverage provided outside the United States. Contact Customer Service for more information. See xxxx://xxxxxxxx.xxxx.xxx • Hearing aids • Non-emergency care when traveling outside the U.S • Private-duty nursing • Routine eye care (Adult)Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 250 person / $600 500 family For non-participating providers: $500 person / $1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $500 person / $1,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Appendix "H" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 7 copay (retail) 30-day retail)/ $15 copay/prescription 14 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 35 copay (retail) 30-day retail)/ $60 copay/prescription 70 copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 70 copay (retail) 30-day retail)/ $90 copay/prescription 140 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 7 copay (specialty pharmacygeneric)/ $35 copay (preferred brand) 50% coinsurance deductible does not apply /$70 copay (non-preferred brand) 44 Not Covered Appendix "H" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2010% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 10% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care No Charge (emergency services)/$50 copay/visit (non-emergency services) No Charge (emergency services)/$50 copay/visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is recommendedwaived if admitted to the hospital or the result of an accidental injury. Emergency medical transportation 10% coinsurance 10% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $20 copay/visit 40% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 10% coinsurance 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $20 copay /visit (office visit) /10% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services 10% coinsurance 40% coinsurance If you are pregnant Office visits No Charge 40% coinsurance Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. Childbirth/delivery professional services 10% coinsurance 40% coinsurance Childbirth/delivery facility services 10% coinsurance 40% coinsurance Appendix "H" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care 10% coinsurance Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 10% coinsurance 10% coinsurance Limited to 120 days per year. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 10% coinsurance 10% coinsurance Preauthorization required for all rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No Charge No Charge Bereavement counseling is covered. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Appendix "H" Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Appendix "H" Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $200 individual, 250 Individual/ $600 family 500 Family $500 Individual/ $1,000 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, Individual/ $12,700 family Out-of-Network: $6,350 per individual, Family $12,700 family Individual/ $25,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 40% coinsurance None Specialist visit $10 20 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 40% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance None Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 10 copay/prescription (retail) $15 copay/prescription (mailfor retail 30-order) Not covered No charge for certain preventive drugsday supply; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/for retail or mail order 90-day supply; deductible does not apply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Preauthorization, step therapy and quantity limits may apply to select drugs. Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription (maildrug program. Preferred brand-order) Not covered Tier 3/Non-preferred brand name drugs $30 copay/prescription (retail) for retail 30-day supply; $90 60 copay/prescription (mailfor retail or mail order 90-order) Not covered Tier 4/Specialty day supply; deductible does not apply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Nonpreferred brand-name drugs $30 60 copay/prescription (specialty pharmacy) 50for retail 30-day supply; $120 copay/prescription for retail or mail order 90-day supply; deductible does not apply In-Network copay plus an additional 25% coinsurance of the approved amount; deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2010% coinsurance Preauthorization is recommended. 40% coinsurance None Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 2010% coinsurance 40% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit visit; deductible does not apply $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costsor for an accidental injury. Emergency medical transportation 10% coinsurance 10% coinsurance Mileage limits apply Urgent care $50 20 copay/trip $50 copay/tripvisit; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No charge 2010% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required Physician/surgeon fees No charge 20fee 10% coinsurance 40% coinsurance None If you need behavioral health services (mental health and substance use disorder) Outpatient services 10% coinsurance 10% coinsurance for mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20; 40% coinsurance 20for substance use disorder Your cost share may be different for services performed in an office setting Inpatient services 10% coinsurance /outpatient services 40% coinsurance Preauthorization is recommended for certain servicesrequired. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply Prenatal: 40% coinsurance Depending on the type of services, Postnatal: 40% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)) and depending on the type of services cost share may apply. Preauthorization is recommendedCost sharing does not apply for preventive services. Childbirth/delivery professional services No charge 2010% coinsurance 40% coinsurance None Childbirth/delivery facility services No charge 2010% coinsurance 40% coinsurance None If you need help recovering or have other special health needs Home health care 10% coinsurance 10% coinsurance Physician certification required. Rehabilitation services $20 copay/visit; deductible does not apply 40% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services 10% coinsurance for Applied Behavioral Analysis; 10% coinsurance for Physical, Speech and Occupational Therapy 10% coinsurance for Applied Behavioral Analysis; 40% coinsurance for Physical, Speech and Occupational Therapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 2010% coinsurance 10% coinsurance Preauthorization is recommendedrequired. Custodial Care is not covered. Limited to 120 days per member per calendar year Durable medical equipment 2010% coinsurance 2010% coinsurance Preauthorization is recommended for certain servicesExcludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge; deductible does not apply No Charge; deductible does not apply Physician certification required. Visit limits apply. If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not covered Not covered None Children’s glasses Not covered Not covered None Children’s dental check-check- up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture treatment • Cosmetic surgery • Dental care (Adult) • Dental check-up, child Hearing aids • Glasses, child Infertility treatment • Long-Long term care • Routine eye care (Adult) • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage Coverage provided outside the United States. Contact Customer Service for more information. See xxxx://xxxxxxxx.xxxx.xxx • Non-emergency care when traveling outside the U.S • Private-duty nursing • Routine eye care (Adult)Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 1,000 person / $600 2,000 family For non-participating providers: $2,000 person / $4,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $2,000 person / $4,000 family (coinsurance only, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays). For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–-of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? Appendix "E" No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 30 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 30 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 15 copay (retail) 30-day retail)/ $15 copay/prescription 30 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90-day supply (mail order prescription), 30-day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 30 copay (retail) 30-day retail)/ $60 copay/prescription copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 60 copay (retail) 30-day retail)/ $90 copay/prescription 120 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 15 copay (specialty pharmacygeneric)/$30 copay (preferred brand)/ $60 copay (non-preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Not Covered Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$150 copay/visit $100 (non-emergency services) No Charge (emergency services)/$150 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 20% coinsurance 20% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 30 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/30 copay /visit (office visit No charge /outpatient visit) /20% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 2040% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Baby does not count Childbirth/delivery professional services No charge 20% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 20% coinsurance 41 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 20% coinsurance 20% coinsurance Includes PhysicalLimited to 120 days per year. Preauthorization required. If you don't get preauthorization, Occupational and Speech Therapybenefits could be reduced by $500 of the total cost of the service. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not coveredNon-participating providers paid at the participating provider level of benefits. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adultfor morbid obesity only)

Important Questions Answers Why This Matters. What is the overall deductible? OutFor in-network providers: $0/individual, $0/individual + 1 or $0/family For out-of-Networknetwork providers: $200 500/individual, $600 1,000/individual + 1 or $1,500/family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room careOut-of-network prescription drugs, emergency medical transportation and some specialty drugs out-of-network urgent care facility visits. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t n't have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? InFor in-Network: network providers $6,350 6,350/individual, $12,700 12,700/individual + 1 or $12,700/family OutFor out-of-Network: network providers $6,350 per 1,500/individual, $12,700 3,000/individual + 1 or $4,500/family Combined medical/behavioral and pharmacy out-of-pocket limit The out-of-pocket limit is the most you could pay in a year for covered services. .If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? PremiumsPenalties for failure to obtain pre-authorization for services, premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t n't count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded serviceslimit.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 15 copay/office visit $10 15 copay/office visit plus 20% coinsurance None Specialist visit $10 20 copay/office visit $10 20 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/ immunization No charge $10 20 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. received You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay20% coinsurance/prescription (retail) $15 copay/prescription (retail & mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. $75 maximum charge per prescription (except infertility drugs); Preauthorization is required for certain drugs Tier 2/Preferred brand drugs $20 copay20% coinsurance/prescription (retail) $60 copay/prescription (retail & mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay20% coinsurance/prescription (retail) $90 copay/prescription (retail & mail-order) Not covered Tier 4/Specialty drugs $30 copay20% coinsurance/prescription (specialty pharmacypharmacy only) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 75 copay/visit $100 75 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge admitted. Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 20 copay/urgent care center visit $10 20 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 20 copay/office visit No charge /outpatient services $10 20 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 20 copay/office visit plus20$20 copay/visit plus 20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Childbirth/delivery facility services No charge 20% coinsurance If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge charge for services to treat autism spectrum disorder and preauthorization is not required required. Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 20 copay/office visit $10 20 copay/office visit plus20plus 20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $200 individual, 250 Individual/ $600 family 500 Family $500 Individual/ $1,000 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, Individual/ $12,700 family Out-of-Network: $6,350 per individual, Family $12,700 family Individual/ $25,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 40% coinsurance None Specialist visit $10 20 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 40% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance None Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 10 copay/prescription (retail) $15 copay/prescription (mailfor retail 30-order) Not covered No charge for certain preventive drugsday supply; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/for retail or mail order 90-day supply; deductible does not apply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Preauthorization, step therapy and quantity limits may apply to select drugs. Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription (maildrug program. Preferred brand-order) Not covered Tier 3/Non-preferred brand name drugs $30 copay/prescription (retail) for retail 30-day supply; $90 60 copay/prescription (mailfor retail or mail order 90-order) Not covered Tier 4/Specialty day supply; deductible does not apply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Nonpreferred brand-name drugs $30 60 copay/prescription (specialty pharmacy) 50for retail 30-day supply; $120 copay/prescription for retail or mail order 90-day supply; deductible does not apply In-Network copay plus an additional 25% coinsurance of the approved amount; deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2010% coinsurance Preauthorization is recommended. 40% coinsurance None Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 2010% coinsurance 40% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit visit; deductible does not apply $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costsor for an accidental injury. Emergency medical transportation 10% coinsurance 10% coinsurance Mileage limits apply Urgent care $50 20 copay/trip $50 copay/tripvisit; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No charge 2010% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required Physician/surgeon fees No charge 20fee 10% coinsurance 40% coinsurance None If you need behavioral health services (mental health and substance use disorder) Outpatient services 10% coinsurance 10% coinsurance for mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20; 40% coinsurance 20for substance use disorder Your cost share may be different for services performed in an office setting Inpatient services 10% coinsurance /outpatient services 40% coinsurance Preauthorization is recommended for certain servicesrequired. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply Prenatal: 40% coinsurance Depending on the type of services, Postnatal: 40% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)) and depending on the type of services cost share may apply. Preauthorization is recommendedCost sharing does not apply for preventive services. Childbirth/delivery professional services No charge 2010% coinsurance 40% coinsurance None Childbirth/delivery facility services No charge 2010% coinsurance 40% coinsurance None If you need help recovering or have other special health needs Home health care 10% coinsurance 10% coinsurance Physician certification required. Rehabilitation services $20 copay/visit; deductible does not apply 40% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services 10% coinsurance for Applied Behavioral Analysis; 10% coinsurance for Physical, Speech and Occupational Therapy 10% coinsurance for Applied Behavioral Analysis; 40% coinsurance for Physical, Speech and Occupational Therapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 2010% coinsurance 10% coinsurance Preauthorization is recommendedrequired. Custodial Care is not covered. Limited to 120 days per member per calendar year Durable medical equipment 2010% coinsurance 2010% coinsurance Preauthorization is recommended for certain servicesExcludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge; deductible does not apply No Charge; deductible does not apply Physician certification required. Visit limits apply. If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not covered Not covered None Children’s glasses Not covered Not covered None Children’s dental check-check- up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture treatment • Cosmetic surgery • Dental care (Adult) • Dental check-up, child Hearing aids • Glasses, child Infertility treatment • Long-Long term care • Routine eye care (Adult) • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage Coverage provided outside the United States. Contact Customer Service for more information. See xxxx://xxxxxxxx.xxxx.xxx • Non-emergency care when traveling outside the U.S • Private-duty nursing • Routine eye care (Adult)Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 250 person / $600 500 family For non-participating providers: $500 person / $1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $6,350 individual, 750 person / $12,700 1,500 family OutFor non-of-Networkparticipating providers: $6,350 per individual, 4,500 person / $12,700 9,000 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-out- of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–-of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xx xxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Appendix "G" Generic drugs $5 copay/prescription 7 copay (retail) 30-day retail)/ $15 copay/prescription 14 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90-day supply (mail order prescription), 30-day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 35 copay (retail) 30-day retail)/ $60 copay/prescription 70 copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 70 copay (retail) 30-day retail)/ $90 copay/prescription 140 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 7 copay (specialty pharmacygeneric)/$35 copay (preferred brand)/ $70 copay (non-preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Page 71 Not Covered Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 2010% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$50 copay/visit $100 (non-emergency services) No Charge (emergency services)/$50 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 10% coinsurance 10% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 20 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 2010% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 2010% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/20 copay /visit (office visit No charge /outpatient services $10 copay/office visit plus 20visit) /10% coinsurance 20(all other outpatient) 40% coinsurance /outpatient services Includes telemedicine consultations by providers other than Teladoc. Preauthorization is recommended required for certain inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services No charge 2010% coinsurance 40% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 2010% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 2010% coinsurance 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) services described elsewhere in the SBC (i.e. ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 2010% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services 20No Charge (services related to autism)/10% coinsurance 20(all other services) 40% coinsurance Includes Physical, Occupational and Speech Therapyspeech & occupational therapy limited to a combined maximum of 60 visits per year. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. Habilitation services No Charge for (services related to treat autism spectrum disorder and preauthorization is not required Habilitation services 20autism)/10% coinsurance 20(all other services) 40% coinsurance ----------------none---------------- Skilled nursing care No charge 2010% coinsurance 10% coinsurance Limited to 120 days per year. Preauthorization is recommendedrequired. Custodial Care is not coveredIf you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 2010% coinsurance 2010% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non- participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) the service. Respite care limited to 5 days per 30-day period. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 1,000 person / $600 2,000 family For non-participating providers: $2,000 person / $4,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $2,000 person / $4,000 family (coinsurance only, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays). For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–-of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 30 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 30 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 15 copay (retail) 30-day retail)/ $15 copay/prescription 30 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90-day supply (mail order prescription), 30-day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 30 copay (retail) 30-day retail)/ $60 copay/prescription copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 60 copay (retail) 30-day retail)/ $90 copay/prescription 120 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 15 copay (specialty pharmacygeneric)/$30 copay (preferred brand)/ $60 copay (non-preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Not Covered Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$150 copay/visit $100 (non-emergency services) No Charge (emergency services)/$150 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 20% coinsurance 20% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 30 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/30 copay /visit (office visit No charge /outpatient visit) /20% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 2040% coinsurance If you are pregnant Appendix "E" Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Baby does not count Childbirth/delivery professional services No charge 20% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Page 58 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 20% coinsurance 20% coinsurance Includes PhysicalLimited to 120 days per year. Preauthorization required. If you don't get preauthorization, Occupational and Speech Therapybenefits could be reduced by $500 of the total cost of the service. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not coveredNon-participating providers paid at the participating provider level of benefits. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 500 person / $600 1,000 family For non-participating providers: $1,000 person / $2,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $1,500 person / $3,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 15 copay (retail) 30-day retail)/ $15 copay/prescription 30 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 30 copay (retail) 30-day retail)/ $60 copay/prescription copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 60 copay (retail) 30-day retail)/ $90 copay/prescription 120 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 15 copay (specialty pharmacygeneric)/$30 copay (preferred brand)/ $60 copay (non-preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. 33 Not Covered Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$100 copay/visit $100 (non-emergency services) No Charge (emergency services)/$100 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 20% coinsurance 20% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 20 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/20 copay /visit (office visit No charge /outpatient visit) /20% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 2040% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 20% coinsurance 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 20% coinsurance 20% coinsurance Includes PhysicalLimited to 120 days per year. Preauthorization required. If you don't get preauthorization, Occupational and Speech Therapybenefits could be reduced by $500 of the total cost of the service. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not coveredNon-participating providers paid at the participating provider level of benefits. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adultfor morbid obesity only)

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $100 Individual/ $200 individual, Family $600 family 250 Individual/ $500 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, Individual/ $12,700 family Out-of-Network: $6,350 per individual, Family $12,700 family Individual/ $25,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 30% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20visit; deductible does not apply 30% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 30% coinsurance None Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 30% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 copay/prescription (retail) 10 copay for retail 30-day supply; $15 copay/prescription (mail10 copay for retail or mail order 90-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsuranceday supply; deductible does not applyapply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Preauthorization, step therapy and quantity limits may apply to select drugs. Tier 2/Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription drug program. Preferred brand brand-name drugs $20 copay/prescription (retail) copay for retail 30-day supply; $60 copay/prescription (mail20 copay for retail or mail order 90-order) Not covered Tier 3/Nonday supply; deductible does not apply In-preferred brand Network copay plus an additional 25% of the approved amount; deductible does not apply Nonpreferred brand-name drugs $30 copay/prescription (retail) 20 copay for retail 30-day supply; $90 copay/prescription (mail20 copay for retail or mail order 90-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50day supply; deductible does not apply In-Network copay plus an additional 25% coinsurance of the approved amount; deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2010% coinsurance Preauthorization is recommended30% coinsurance None Physician/surgeon fees 10% coinsurance 30% coinsurance None If you need immediate medical attention Emergency room care $50 copay/visit; deductible does not apply $50 copay/visit; deductible does not apply Copay waived if admitted or for an accidental injury. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20Emergency medical transportation 10% coinsurance None If you need immediate medical attention Emergency room 10% coinsurance Mileage limits apply Urgent care $100 copay/visit $100 10 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 2030% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No charge 2010% coinsurance 45 day limit at an inpatient rehabilitation facility; 30% coinsurance Preauthorization is recommended required Physician/surgeon fees No charge 20fee 10% coinsurance 30% coinsurance None If you need behavioral health services (mental health and substance use disorder) Outpatient services 10% coinsurance 10% coinsurance for mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20; 30% coinsurance 20for substance use disorder Your cost share may be different for services performed in an office setting Inpatient services 10% coinsurance /outpatient services 30% coinsurance Preauthorization is recommended for certain servicesrequired. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply Prenatal: 30% coinsurance Depending on the type of services, Postnatal: 30% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)) and depending on the type of services cost share may apply. Preauthorization is recommendedCost sharing does not apply for preventive services. Childbirth/delivery professional services No charge 2010% coinsurance 30% coinsurance None Childbirth/delivery facility services No charge 2010% coinsurance 30% coinsurance None If you need help recovering or have other special health needs Home health care 10% coinsurance 10% coinsurance Physician certification required. Rehabilitation services 10% coinsurance 30% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services 10% coinsurance for Applied Behavioral Analysis; 10% coinsurance for Physical, Speech and Occupational Therapy 10% coinsurance for Applied Behavioral Analysis; 30% coinsurance for Physical, Speech and Occupational Therapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Skilled nursing care 10% coinsurance 10% coinsurance Preauthorization is required. Limited to 120 days per member per calendar year Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 2010% coinsurance 2010% coinsurance Preauthorization is recommended for certain servicesExcludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge; deductible does not apply No Charge; deductible does not apply Physician certification required. Visit limits apply. If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not covered Not covered None Children’s glasses Not covered Not covered None Children’s dental check-check- up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture treatment • Cosmetic surgery • Dental care (Adult) • Dental check-up, child Hearing aids • Glasses, child Infertility treatment • Long-Long term care • Routine eye care (Adult) • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage Coverage provided outside the United States. Contact Customer Service for more information. See xxxx://xxxxxxxx.xxxx.xxx • Non-emergency care when traveling outside the U.S • Private-duty nursing • Routine eye care (Adult)Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 250 person / $600 500 family For non-participating providers: $500 person / $1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $500 person / $1,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Appendix "F" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 7 copay (retail) 30-day retail)/ $15 copay/prescription 14 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 35 copay (retail) 30-day retail)/ $60 copay/prescription 70 copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 70 copay (retail) 30-day retail)/ $90 copay/prescription 140 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 7 copay (specialty pharmacygeneric)/ $35 copay (preferred brand) 50% coinsurance deductible does not apply /$70 copay (non-preferred brand) 52 Not Covered Appendix "F" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2010% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 10% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care No Charge (emergency services)/$50 copay/visit (non-emergency services) No Charge (emergency services)/$50 copay/visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is recommendedwaived if admitted to the hospital or the result of an accidental injury. Emergency medical transportation 10% coinsurance 10% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $20 copay/visit 40% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 10% coinsurance 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $20 copay /visit (office visit) /10% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services 10% coinsurance 40% coinsurance If you are pregnant Office visits No Charge 40% coinsurance Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. Childbirth/delivery professional services 10% coinsurance 40% coinsurance Childbirth/delivery facility services 10% coinsurance 40% coinsurance Appendix "F" Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care 10% coinsurance Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 10% coinsurance 10% coinsurance Limited to 120 days per year. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 10% coinsurance 10% coinsurance Preauthorization required for all rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No Charge No Charge Bereavement counseling is covered. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Appendix "F" Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Appendix "F" Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of 0 See the Common Medical Events chart below for your costs from providers up to the deductible amount before for services this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductiblecovers. Are there services covered before you meet your deductible? YesNo. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met You will have to meet the deductible amount. But a copayment or coinsurance may applybefore the plan pays for any services. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network$1,500 Individual/$3,000 Family Prescription drug expense limit: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family 500 Individual/$1,500 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-of- pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxx.xxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network participating providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral Referral to see a specialist? NoYes. You can This plan will pay some or all of the costs to see a specialist for covered services but only if you have a Referral before you see the specialist you choose without a referralspecialist. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 30 copay/office visit $10 copay/office visit plus 20% coinsurance None Not Covered Services or supplies that are not ordered by your Primary Care Physician or Women’s Principal Health Care Provider, except emergency and routine vision exams, are not covered. Specialist visit $10 50 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Not Covered Referral required. Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge Not Covered You may have to pay for services that aren’t preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain servicesCharge Not Covered Referral required. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Charge Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommendedCovered Referral required. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxxxxx.xxx. Generic drugs $10 copay/prescription (retail) $20 copay/prescription (mail order) Not Covered Dispensing limit may apply to certain drugs. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Certain women’s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. 30-day retail/90-day mail. RX Out-of-Pocket Expense Limit: $500 Individual/$1,500 Family. Preferred brand drugs $40 copay/prescription (retail) $80 copay/prescription (mail order) Not Covered Non-preferred brand drugs $60 copay/prescription (retail) $120 copay/prescription (mail order) Not Covered Specialty drugs Applicable copay Not Covered Coverage based on group policy. Prior authorization may be required. Specialty retail limited to a 30-day supply. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge Not Covered Referral required. Physician/surgeon fees No charge 20% coinsurance None Charge Not Covered Referral required. If you need immediate medical attention Emergency room care $100 500 copay/visit $100 500 copay/visit; deductible does not apply Emergency room: visit Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costsadmitted. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply No Charge No Charge Ground transportation only. Urgent care $10 30 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance Not Covered Must be affiliated with member’s chosen medical group or referral required. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended $250 copay/admission Not Covered Referral required. Physician/surgeon fees No charge 20% coinsurance None Charge Not Covered Referral required. If you need mental health, behavioral health, or substance abuse services Outpatient services $10 30 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicesNot Covered Unlimited visits. Referral required. Inpatient services No charge 20% coinsurance $250 copay/admission Not Covered Unlimited days. Referral required. If you are pregnant Office visits $10 30 copay/visit $10 copay/office Not Covered Copay applies for the 1st prenatal visit plus20% coinsurance only. Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance a copayment may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Charge Not Covered Childbirth/delivery facility services $250 copay/admission Not Covered Referral required. If you need help recovering or have other special health needs Home health care No charge 20% coinsurance Charge Not Covered Referral required. Rehabilitation services $30 copay/visit Not Covered 60 visits combined for all therapies. Referral required. Habilitation services $30 copay/visit Not Covered Skilled nursing care $250 copay/admission Not Covered Excludes custodial care. Referral required. Durable medical equipment No Charge Not Covered Referral required. Benefits are limited to items used to serve a medical purpose. Durable Medical Equipment benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice services No Charge Not Covered Inpatient copay may apply. Referral required. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance No Charge Not Covered Limited to one routine eye exam per yearevery 12 months at participating providers. Children’s glasses Not covered Covered Not covered Covered None Children’s dental check-up Not covered Covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)None

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx or by calling 1- 800-639-2227or (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. received You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay20% coinsurance/prescription (retail) $15 copay/prescription (retail & mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay20% coinsurance/prescription (retail) $60 copay/prescription (retail & mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay20% coinsurance/prescription (retail) $90 copay/prescription (retail & mail-order) Not covered Tier 4/Specialty drugs $30 copay20% coinsurance/prescription (specialty pharmacypharmacy only) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 75 copay/visit $100 75 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge admitted. Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/office visit $10 copay/office visit plus20plus 20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20plus 20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-$3000 Single (Paramount Ohio HMO Network: .) $200 individual, $600 family 6000 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles otherdeductibles for specific services? No. No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-$3000 Single (Paramount Ohio HMO Network: .) $6,350 individual, $12,700 family Out-of-6000 Family(Paramount Ohio HMO Network: $6,350 per individual, $12,700 family .) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-out- of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in includedin the out-of-pocket limit? Premiums, balance-billing charges, Premiums and health care this plan doesn’t n't cover. Even though you pay these expenses, they don’t count toward the out–of–– pocket limit. Will you pay less if you ifyou use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network providersParamount Ohio HMO Network Providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s 's charge and what your plan pays (a balance billingbill). Be aware, aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral areferral to see a specialist? No. No You can see the specialist you choose without a referral. 58 HSA All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s 's office or clinic Primary care Care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None No charge. Not covered. –––––––––––none––––––––––– Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits No charge. Not covered. –––––––––––none––––––––––– Preventive care/screening/ immunization screening /immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services receivedcharge. Not covered. You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxxxxxxx.xxxxxxxxxxxxxxxxxxx.xxx/Xxxxxxxxx- PharmacyResources-CommercialDrugBenefits Prescription Drug Coverage Not Covered By Paramount. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not applyCovered By Paramount. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply Covered By Paramount. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommendedcharge. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costscharge. Payable under HMO network of benefits. –––––––––––none––––––––––– Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended charge. Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Inpatient services No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on No charge. Not covered. Cost sharing does not apply for preventive services. *For more information about limitations and exceptions, see the type of services, coinsurance may applyplan or policy document at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance HSA HSA Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you are pregnant Childbirth/delivery professional services No charge. Not covered. –––––––––––none––––––––––– Childbirth/delivery facility services No charge. Not covered. –––––––––––none––––––––––– If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None charge. Not covered. In Lieu of Hospitalization Rehabilitation services 20% coinsurance 20% coinsurance Includes PhysicalNo charge. Not covered. Outpatient physical, Occupational occupational and Speech Therapyspeech therapy limited to 30 visits combined. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance No charge. Not covered. Outpatient physical, occupational and speech therapy limited to 30 visits combined. Skilled nursing care No charge 20% coinsurance Preauthorization is recommendedcharge. Custodial Care is not Not covered. Unliimited days. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo charge. Not covered. Subject to Medicare part B Guidelines. Hospice services No charge 20% coinsurance Preauthorization is recommendedcharge. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Children’s 's eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance No charge. Not covered. Limited to one (1) routine eye vision exam per yearevery twelve (12) months. Children’s 's glasses Not covered covered. Not covered None covered. –––––––––––none––––––––––– Children’s 's dental check-up Not covered covered. Not covered None covered. –––––––––––none––––––––––– Excluded Services & Other Covered Services: HSA Services Your Plan Generally Does NOT Cover cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental checkPrivate-up, child duty nursing • Glasses, child Bariatric Surgery • Long-term care • Routine foot care unless to treat a systemic condition • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t n't a complete list. Please see check your plan document.) • Bariatric Surgery . • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatment (Excludes infertility drugs) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration, 1-866-444-EBSA (3272), xxx.xxx.xxx/xxxx/xxxxxxxxxxxx

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 250 person / $600 500 family For non-participating providers: $500 person / $1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $500 person / $1,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Appendix "E" - Plan #50 - Michigan Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 7 copay (retail) 30-day retail)/ $15 copay/prescription 14 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 35 copay (retail) 30-day retail)/ $60 copay/prescription 70 copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 70 copay (retail) 30-day retail)/ $90 copay/prescription 140 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 7 copay (specialty pharmacygeneric)/ $35 copay (preferred brand) 50% coinsurance deductible does not apply /$70 copay (non-preferred brand) 74 Not Covered Appendix "E" - Plan #50 - Michigan Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2010% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 10% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care No Charge (emergency services)/$50 copay/visit (non-emergency services) No Charge (emergency services)/$50 copay/visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is recommendedwaived if admitted to the hospital or the result of an accidental injury. Emergency medical transportation 10% coinsurance 10% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $20 copay/visit 40% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 10% coinsurance 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $20 copay /visit (office visit) /10% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services 10% coinsurance 40% coinsurance If you are pregnant Office visits No Charge 40% coinsurance Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. Childbirth/delivery professional services 10% coinsurance 40% coinsurance Childbirth/delivery facility services 10% coinsurance 40% coinsurance Appendix "E" - Plan #50 - Michigan Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care 10% coinsurance Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 10% coinsurance 10% coinsurance Limited to 120 days per year. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 10% coinsurance 10% coinsurance Preauthorization required for all rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No Charge No Charge Bereavement counseling is covered. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Appendix "E" - Plan #50 - Michigan Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Appendix "E" - Plan #50 - Michigan Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-$300 Single (Paramount Ohio HMO Network: $200 individual, .) $600 family Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles otherdeductibles for specific services? No. No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-$2000 Single (Paramount Ohio HMO Network: .) $6,350 individual, $12,700 family Out-of-4000 Family(Paramount Ohio HMO Network: $6,350 per individual, $12,700 family .) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-out- of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in includedin the out-of-pocket limit? Premiums, balance-billing charges, Premiums and health care this plan doesn’t n't cover. Even though you pay these expenses, they don’t count toward the out–of–– pocket limit. Will you pay less if you ifyou use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network providersParamount Ohio HMO Network Providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s 's charge and what your plan pays (a balance billingbill). Be aware, aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral areferral to see a specialist? No. No You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s 's office or clinic Primary care Care visit to treat an injury or illness $10 copay25.00 Co-pay/office visit $10 copay/office visit plus 20% coinsurance None visit. Not covered. –––––––––––none––––––––––– Specialist visit $10 copay35.00 Co-pay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits visit. Not covered. –––––––––––none––––––––––– Preventive care/screening/ immunization screening /immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services receivedcharge. Not covered. You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2015% coinsurance Preauthorization is recommended for certain servicesCo-Insurance. Not covered. –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) No charge 2015% coinsurance Co-Insurance. Not covered. –––––––––––none––––––––––– If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxxxxxxx.xxxxxxxxxxxxxxxxxxx.xxx/Xxxxxxxxx- PharmacyResources-CommercialDrugBenefits Prescription Drug Coverage Not Covered By Paramount. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not applyCovered By Paramount. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply Covered By Paramount. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 2015% coinsurance Preauthorization is recommendedCo-Insurance. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 2015% coinsurance None Co-Insurance. Not covered. –––––––––––none––––––––––– If you need immediate medical attention Emergency room care $100 copay/visit $100 copay100.00 Co-pay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Payable under HMO network of benefits. –––––––––––none––––––––––– Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 15% Co-Insurance. Payable under HMO network of benefits. –––––––––––none––––––––––– Urgent care $10 copay15.00 Co-pay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance visit. Payable under HMO network of benefits. –––––––––––none––––––––––– If you have a hospital stay Facility fee (e.g., hospital room) No charge 2015% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Co-Insurance. Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 2015% coinsurance None Co-Insurance. Not covered. –––––––––––none––––––––––– If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay25.00 Co-pay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicesvisit. Not covered. –––––––––––none––––––––––– Inpatient services No charge 2015% coinsurance Co-Insurance. Not covered. –––––––––––none––––––––––– If you are pregnant Office visits $10 copay35.00 Co-pay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may visit. Not covered. Deductible does not apply. Maternity care may include tests Cost sharing does not apply for preventive services. 55 *For more information about limitations and services described elsewhere in exceptions, see the SBC (i.e. ultrasound)plan or policy document at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. Preauthorization is recommendedPLAN 2 Your Cost If You Use A(n) Paramount Ohio HMO Network. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services Provider Your Cost If You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you are pregnant Childbirth/delivery professional services 15% Co-Insurance. Not covered. –––––––––––none––––––––––– Childbirth/delivery facility services 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If you need help recovering or have other special health needs Home health care No charge 2015% coinsurance None Co-Insurance. Not covered. –––––––––––none––––––––––– Rehabilitation services 2015% coinsurance 20% coinsurance Includes PhysicalCo-Insurance. Not covered. Inpatient Rehabilitation is limited to 60 days per calendar year. Outpatient physical, Occupational occupational and Speech Therapyspeech therapy limited to 30 visits combined. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 2015% coinsurance 20% coinsurance Co-Insurance. Not covered. Inpatient Habilitation is limited to 60 days per calendar year. Outpatient physical, occupational and speech therapy limited to 30 visits combined. Skilled nursing care No charge 2015% coinsurance Preauthorization is recommendedCo-Insurance. Custodial Care is not Not covered. Unliimited days. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo charge. Not covered. Subject to Medicare part B Guidelines. Hospice services No charge 2015% coinsurance Preauthorization is recommendedCo-Insurance. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Children’s 's eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance No charge. Not covered. Limited to one (1) routine eye vision exam per yearevery twelve (12) months. Children’s 's glasses Not covered covered. Not covered None covered. –––––––––––none––––––––––– Children’s 's dental check-up Not covered covered. Not covered None covered. –––––––––––none––––––––––– 56 Excluded Services & Other Covered Services: PLAN 2 Services Your Plan Generally Does NOT Cover cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental checkPrivate-up, child duty nursing • Glasses, child Bariatric Surgery • Long-term care • Routine foot care unless to treat a systemic condition • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t n't a complete list. Please see check your plan document.) • Bariatric Surgery . • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatment (Excludes infertility drugs) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration, 1-866-444-EBSA (3272), xxx.xxx.xxx/xxxx/xxxxxxxxxxxx

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-$3000 Single (Paramount Ohio HMO Network: .) $200 individual, $600 family 6000 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles otherdeductibles for specific services? No. No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-$3000 Single (Paramount Ohio HMO Network: .) $6,350 individual, $12,700 family Out-of-6000 Family(Paramount Ohio HMO Network: $6,350 per individual, $12,700 family .) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-out- of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in includedin the out-of-pocket limit? Premiums, balance-billing charges, Premiums and health care this plan doesn’t n't cover. Even though you pay these expenses, they don’t count toward the out–of–– pocket limit. Will you pay less if you ifyou use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network providersParamount Ohio HMO Network Providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s 's charge and what your plan pays (a balance billingbill). Be aware, aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral areferral to see a specialist? No. No You can see the specialist you choose without a referral. HSA All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s 's office or clinic Primary care Care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None No charge. Not covered. –––––––––––none––––––––––– Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits No charge. Not covered. –––––––––––none––––––––––– Preventive care/screening/ immunization screening /immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services receivedcharge. Not covered. You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxxxxxxx.xxxxxxxxxxxxxxxxxxx.xxx/Xxxxxxxxx- PharmacyResources-CommercialDrugBenefits Prescription Drug Coverage Not Covered By Paramount. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not applyCovered By Paramount. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply Covered By Paramount. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommendedcharge. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costscharge. Payable under HMO network of benefits. –––––––––––none––––––––––– Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended charge. Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need mental health, behavioral health, ,or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Inpatient services No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on No charge. Not covered. Cost sharing does not apply for preventive services. 44 *For more information about limitations and exceptions, see the type of services, coinsurance may applyplan or policy document at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance HSA HSA Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you are pregnant Childbirth/delivery professional services No charge. Not covered. –––––––––––none––––––––––– Childbirth/delivery facility services No charge. Not covered. –––––––––––none––––––––––– If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None charge. Not covered. In Lieu of Hospitalization Rehabilitation services 20% coinsurance 20% coinsurance Includes PhysicalNo charge. Not covered. Outpatient physical, Occupational occupational and Speech Therapyspeech therapy limited to 30 visits combined. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance No charge. Not covered. Outpatient physical, occupational and speech therapy limited to 30 visits combined. Skilled nursing care No charge 20% coinsurance Preauthorization is recommendedcharge. Custodial Care is not Not covered. Unliimited days. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo charge. Not covered. Subject to Medicare part B Guidelines. Hospice services No charge 20% coinsurance Preauthorization is recommendedcharge. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Children’s 's eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance No charge. Not covered. Limited to one (1) routine eye vision exam per yearevery twelve (12) months. Children’s 's glasses Not covered covered. Not covered None covered. –––––––––––none––––––––––– Children’s 's dental check-up Not covered covered. Not covered None covered. –––––––––––none––––––––––– Excluded Services & Other Covered Services: HSA Services Your Plan Generally Does NOT Cover cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental checkPrivate-up, child duty nursing • Glasses, child Bariatric Surgery • Long-term care • Routine foot care unless to treat a systemic condition • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t n't a complete list. Please see check your plan document.) • Bariatric Surgery . • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatment (Excludes infertility drugs) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration, 1-866-444-EBSA (3272), xxx.xxx.xxx/xxxx/xxxxxxxxxxxx

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-Network: $200 individual, $600 family Generally, you must pay all of 0 See the Common Medical Events chart below for your costs from providers up to the deductible amount before for services this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductiblecovers. Are there services covered before you meet your deductible? YesNo. Emergency room care, emergency medical transportation and some specialty drugs This plan covers some items and services even if you haven’t yet met You will have to meet the deductible amount. But a copayment or coinsurance may applybefore the plan pays for any services. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network$1,500 Individual/$3,000 Family Prescription drug expense limit: $6,350 individual, $12,700 family Out-of-Network: $6,350 per individual, $12,700 family 500 Individual/$1,500 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-of- pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxx.xxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network participating providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not apply. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental check-up, child • Glasses, child • Long-term care • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult)

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 500 person / $600 1,000 family For non-participating providers: $1,000 person / $2,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $1,500 person / $3,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Appendix "D" Generic drugs $5 copay/prescription 15 copay (retail) 30-day retail)/ $15 copay/prescription 30 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 30 copay (retail) 30-day retail)/ $60 copay/prescription copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 60 copay (retail) 30-day retail)/ $90 copay/prescription 120 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 15 copay (specialty pharmacygeneric)/$30 copay (preferred brand)/ $60 copay (non-preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. Page 50 Not Covered Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$100 copay/visit $100 (non-emergency services) No Charge (emergency services)/$100 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 20% coinsurance 20% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 20 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/20 copay /visit (office visit No charge /outpatient visit) /20% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 2040% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 20% coinsurance 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 20% coinsurance 20% coinsurance Includes PhysicalLimited to 120 days per year. Preauthorization required. If you don't get preauthorization, Occupational and Speech Therapybenefits could be reduced by $500 of the total cost of the service. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not coveredNon-participating providers paid at the participating provider level of benefits. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-$3000 Single (Paramount Ohio HMO Network: .) $200 individual, $600 family 6000 Family (Paramount Ohio HMO Network.) Does not apply to preventive care or covered services requiring a copayment. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs preventive care This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles otherdeductibles for specific services? No. No (Paramount Ohio HMO Network.) You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-$3000 Single (Paramount Ohio HMO Network: .) $6,350 individual, $12,700 family Out-of-6000 Family(Paramount Ohio HMO Network: $6,350 per individual, $12,700 family .) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-out- of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in includedin the out-of-pocket limit? Premiums, balance-billing charges, Premiums and health care this plan doesn’t n't cover. Even though you pay these expenses, they don’t count toward the out–of–– pocket limit. Will you pay less if you ifyou use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxxxxxxxxxxxxxxxx.xxx/XxxxXXxxxxxxx or by calling 1- 800call 0-639000-2227or (000) 000-0000 for a list of network providersParamount Ohio HMO Network Providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s 's charge and what your plan pays (a balance billingbill). Be aware, aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral areferral to see a specialist? No. No You can see the specialist you choose without a referral. HSA All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s 's office or clinic Primary care Care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus 20% coinsurance None No charge. Not covered. –––––––––––none––––––––––– Specialist visit $10 copay/office visit $10 copay/office visit plus 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits No charge. Not covered. –––––––––––none––––––––––– Preventive care/screening/ immunization screening /immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services receivedcharge. Not covered. You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxxxxxxx.xxxxxxxxxxxxxxxxxxx.xxx/Xxxxxxxxx- PharmacyResources-CommercialDrugBenefits Prescription Drug Coverage Not Covered By Paramount. Tier 1/Generic drugs $5 copay/prescription (retail) $15 copay/prescription (mail-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible does not applyCovered By Paramount. Tier 2/Preferred brand drugs $20 copay/prescription (retail) $60 copay/prescription (mail-order) Not covered Tier 3/Non-preferred brand drugs $30 copay/prescription (retail) $90 copay/prescription (mail-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50% coinsurance deductible does not apply Covered By Paramount. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommendedcharge. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costscharge. Payable under HMO network of benefits. –––––––––––none––––––––––– Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance No charge. Payable under HMO network of benefits. –––––––––––none––––––––––– If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended charge. Not covered. –––––––––––none––––––––––– Physician/surgeon fees No charge 20% coinsurance None charge. Not covered. –––––––––––none––––––––––– If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain servicescharge. Not covered. –––––––––––none––––––––––– Inpatient services No charge 20% coinsurance charge. Not covered. –––––––––––none––––––––––– If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on No charge. Not covered. Cost sharing does not apply for preventive services. 55 *For more information about limitations and exceptions, see the type of services, coinsurance may applyplan or policy document at xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance HSA HSA Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, Exceptions & Other Important Information Network Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider (Your Cost If You will pay the leastUse A(n) Out-of-Network Provider (You will pay the most) If you are pregnant Childbirth/delivery professional services No charge. Not covered. –––––––––––none––––––––––– Childbirth/delivery facility services No charge. Not covered. –––––––––––none––––––––––– If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None charge. Not covered. In Lieu of Hospitalization Rehabilitation services 20% coinsurance 20% coinsurance Includes PhysicalNo charge. Not covered. Outpatient physical, Occupational occupational and Speech Therapyspeech therapy limited to 30 visits combined. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance No charge. Not covered. Outpatient physical, occupational and speech therapy limited to 30 visits combined. Skilled nursing care No charge 20% coinsurance Preauthorization is recommendedcharge. Custodial Care is not Not covered. Unliimited days. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo charge. Not covered. Subject to Medicare part B Guidelines. Hospice services No charge 20% coinsurance Preauthorization is recommendedcharge. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Children’s 's eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance No charge. Not covered. Limited to one (1) routine eye vision exam per yearevery twelve (12) months. Children’s 's glasses Not covered covered. Not covered None covered. –––––––––––none––––––––––– Children’s 's dental check-up Not covered covered. Not covered None covered. –––––––––––none––––––––––– Excluded Services & Other Covered Services: HSA Services Your Plan Generally Does NOT Cover cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (Adult) • Dental checkPrivate-up, child duty nursing • Glasses, child Bariatric Surgery • Long-term care • Routine foot care unless to treat a systemic condition • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t n't a complete list. Please see check your plan document.) • Bariatric Surgery . • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • Private-duty nursing • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatment (Excludes infertility drugs) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration, 1-866-444-EBSA (3272), xxx.xxx.xxx/xxxx/xxxxxxxxxxxx

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 500 person / $600 1,000 family For non-participating providers: $1,000 person / $2,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $1,500 person / $3,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Appendix "C" - Plan #048 - Ontario Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 15 copay (retail) 30-day retail)/ $15 copay/prescription 30 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 30 copay (retail) 30-day retail)/ $60 copay/prescription copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 60 copay (retail) 30-day retail)/ $90 copay/prescription 120 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 15 copay (specialty pharmacygeneric)/$30 copay (preferred brand)/ $60 copay (non-preferred brand) 50% coinsurance deductible does not apply 60 Not Covered Appendix "C" - Plan #048 - Ontario Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 20% coinsurance 40% coinsurance If you need immediate medical attention Emergency room care No charge Charge (emergency services)/$100 copay/visit (non-emergency services) No Charge (emergency services)/$100 copay/visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted to the hospital or the result of an accidental injury. Emergency medical transportation 20% coinsurance 20% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $20 copay/visit 40% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees 20% coinsurance 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $20 copay /visit (office visit) /20% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services 20% coinsurance 40% coinsurance If you are pregnant Office visits No Charge 40% coinsurance Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. Childbirth/delivery professional services 20% coinsurance 40% coinsurance Childbirth/delivery facility services 20% coinsurance 40% coinsurance Appendix "C" - Plan #048 - Ontario Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care 20% coinsurance Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 20% coinsurance 20% coinsurance Limited to 120 days per year. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization required for all rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No Charge No Charge Bereavement counseling is recommendedcovered. Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Rehabilitation services 20% coinsurance 20% coinsurance Includes Physical, Occupational and Speech Therapy. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not covered. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain services. Hospice services No charge 20% coinsurance Preauthorization is recommended. If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Appendix "C" - Plan #048 - Ontario Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adult)for morbid obesity only) Appendix "C" - Plan #048 - Ontario Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at (000) 000-0000 x 00000 or xxx.xxxxx.xxx.xxx, or Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call (000) 000-0000.

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 500 person / $600 1,000 family For non-participating providers: $1,000 person / $2,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $1,500 person / $3,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 15 copay (retail) 30-day retail)/ $15 copay/prescription 30 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 30 copay (retail) 30-day retail)/ $60 copay/prescription copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 60 copay (retail) 30-day retail)/ $90 copay/prescription 120 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 15 copay (specialty pharmacygeneric)/$30 copay (preferred brand)/ $60 copay (non-preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Preauthorization is recommended. 45 Not Covered Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$100 copay/visit $100 (non-emergency services) No Charge (emergency services)/$100 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 20% coinsurance 20% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 20 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 20% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/20 copay /visit (office visit No charge /outpatient visit) /20% coinsurance (all other outpatient) 40% coinsurance Includes telemedicine consultations by providers other than Teladoc. Preauthorization required for inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 2040% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 20% coinsurance 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 20% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services No Charge (services related to autism)/10% coinsurance (all other services) 40% coinsurance Physical, speech & occupational therapy limited to a combined maximum of 60 visits per year. Habilitation services No Charge (services related to autism)/20% coinsurance (all other services) 40% coinsurance ----------------none---------------- Skilled nursing care 20% coinsurance 20% coinsurance Includes PhysicalLimited to 120 days per year. Preauthorization required. If you don't get preauthorization, Occupational and Speech Therapybenefits could be reduced by $500 of the total cost of the service. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Preauthorization is recommended. Custodial Care is not coveredNon-participating providers paid at the participating provider level of benefits. Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adultfor morbid obesity only)

Important Questions Answers Why This Matters. What is the overall deductible? Out-of-NetworkFor participating providers: $200 individual, 250 person / $600 500 family For non-participating providers: $500 person / $1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room For participating providers: Preventive care, emergency medical transportation and some specialty drugs room care (all providers), urgent care, hospice services (all providers), autism therapies, office visits, prenatal & postnatal services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxx.xxxxxxxxxx.xxx/xxxxxxxx/xxxxxxxxxx-xxxx-xxxxxxxx/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-NetworkFor participating providers: $500 person / $1,000 family (coinsurance, except for private duty nursing) $6,350 individual, person / $12,700 family Out(deductible, coinsurance and copays) For non-of-Networkparticipating providers: $6,350 per individual4,000 person / $8,000 family (coinsurance, except for private duty nursing) $12,700 person / $25,400 family (deductible, coinsurance and copays) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-preauthorization penalty amounts, balance billing charges, charges and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–out- of–-pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or by calling 1- 800-639-2227or call (000) 000-0000 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-of- network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance None Copay applies per visit regardless of what services are rendered. Includes telemedicine consultations by providers other than Teladoc. There is no charge and the deductible does not apply if you receive consultation services through Teladoc. Specialist visit $10 20 copay/office visit $10 copay/office visit plus 2040% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits Preventive care/screening/ immunization No charge $10 copay/office visit plus 20Charge 40% coinsurance Member liability for Out-of-Network is based on services received. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge 2010% coinsurance Preauthorization is recommended for certain services. 40% coinsurance ----------------none---------------- Imaging (CT/PET scans, MRIs) No charge 2010% coinsurance 40% coinsurance Preauthorization required for MRI/MRA & PET scans. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxxxxxxx.xxx Generic drugs $5 copay/prescription 7 copay (retail) 30-day retail)/ $15 copay/prescription 14 copay (mail90-day retail & mail order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsurance; deductible Covered Deductible does not apply. Tier 2/Covers up to a 90-day supply (retail prescription); 90- day supply (mail order prescription), 30- day supply (specialty drugs). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs are only available through the approved Archimedes specialty pharmacy network. A list of specialty drugs can be found at: xxxxx://xxxxxxxxxxxx.xxx/resources/. Preferred brand drugs $20 copay/prescription 35 copay (retail) 30-day retail)/ $60 copay/prescription 70 copay (mail90-day retail & mail order) Not covered Tier 3/Covered Non-preferred brand drugs $30 copay/prescription 70 copay (retail) 30-day retail)/ $90 copay/prescription 140 copay (mail90-day retail & mail order) Not covered Tier 4/Covered Specialty drugs $30 copay/prescription 7 copay (specialty pharmacygeneric)/ $35 copay (preferred brand) 50% coinsurance deductible does not apply If you have outpatient surgery Facility fee /$70 copay (e.g., ambulatory surgery centernon-preferred brand) No charge 20% coinsurance Preauthorization is recommended. 47 Not Covered Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 40% coinsurance Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 2010% coinsurance None 40% coinsurance If you need immediate medical attention Emergency room care $100 No Charge (emergency services)/$50 copay/visit $100 (non-emergency services) No Charge (emergency services)/$50 copay/visit; deductible does not apply Emergency room: visit (non-emergency services) Non-participating providers paid at the participating provider level of benefits for emergency services. Copay is waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket coststhe hospital or the result of an accidental injury. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply 10% coinsurance 10% coinsurance Non-participating providers paid at the participating provider level of benefits. Urgent care $10 20 copay/urgent care center visit $10 copay/urgent care center visit plus 2040% coinsurance Copay applies per visit regardless of what services are rendered. If you have a hospital stay Facility fee (e.g., hospital room) No charge 2010% coinsurance 45 day limit at an inpatient rehabilitation facility; 40% coinsurance Preauthorization is recommended required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Physician/surgeon fees No charge 2010% coinsurance None 40% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/20 copay /visit (office visit No charge /outpatient services $10 copay/office visit plus 20visit) /10% coinsurance 20(all other outpatient) 40% coinsurance /outpatient services Includes telemedicine consultations by providers other than Teladoc. Preauthorization is recommended required for certain inpatient services, partial hospitalization and intensive outpatient. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Inpatient services No charge 2010% coinsurance 40% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20No Charge 40% coinsurance Depending on Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, benefits could be reduced by $500 of the type total cost of services, coinsurance may applythe service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 2010% coinsurance 40% coinsurance Childbirth/delivery facility services No charge 2010% coinsurance 40% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Participating Provider (You will pay the least) OutNon-of-Network Participating Provider (You will pay the most) ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. If you need help recovering or have other special health needs Home health care No charge 2010% coinsurance None Not Covered Preauthorization required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Rehabilitation services 20No Charge (services related to autism)/10% coinsurance 20(all other services) 40% coinsurance Includes Physical, Occupational and Speech Therapyspeech & occupational therapy limited to a combined maximum of 60 visits per year. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. Habilitation services No Charge for (services related to treat autism spectrum disorder and preauthorization is not required Habilitation services 20autism)/10% coinsurance 20(all other services) 40% coinsurance ----------------none---------------- Skilled nursing care No charge 2010% coinsurance 10% coinsurance Limited to 120 days per year. Preauthorization is recommendedrequired. Custodial Care is not coveredIf you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Durable medical equipment 2010% coinsurance 2010% coinsurance Preauthorization is recommended required for certain servicesall rentals & any purchase over $1,500. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Non-participating providers paid at the participating provider level of benefits. Hospice services No charge 20% coinsurance Charge No Charge Bereavement counseling is covered. Preauthorization is recommendedrequired. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service. Respite care limited to 5 days per 30-day period. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If your child needs dental or eye care Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not Covered Not Covered Not Covered Children’s glasses Not covered Covered Not covered None Covered Not Covered Children’s dental check-up Not covered Covered Not covered None Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Dental care (AdultAdult & Child) • Dental check-up, child Glasses (Adult & Child) • Glasses, child Hearing aids • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult & Child) • Routine foot care unless to treat a systemic condition • Weight loss programs (except for metabolic or peripheral vascular disease) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery (for morbid obesity only) • Chiropractic care • Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. (24 visits per year combined with osteopathic manipulative therapy) • Private-duty nursing • Routine eye care Weight loss programs (Adultfor morbid obesity only)

Important Questions Answers Why This Matters. In-Network Out-of-Network What is the overall deductible? Out-of-Network: $200 individual, 0 $600 family 250 Individual/ $500 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Emergency room care, emergency medical transportation and some specialty drugs Preventive care services are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at xxxxx://xxx.xxxxxxxxxx.xxx/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: (May include a coinsurance maximum) $6,350 individual, Individual/ $12,700 family Out-of-Network: $6,350 per individual, Family $12,700 family Individual/ $25,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-of- pocket limit? Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. Will you pay less if you use a network provider? Yes. See xxx.XXXXXX.xxx xxx.xxxxx.xxx or by calling 1- 800-639-2227or (000) 000-0000 call the number on the back of your BCBSM ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s 's network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay/office visit $10 copay/office visit plus visit; deductible does not apply 20% coinsurance None Specialist visit $10 copay/office visit $10 copay/office visit plus visit; deductible does not apply 20% coinsurance Chiropractic Services are limited to 12 visit(s) per year; $15 copay for allergy and dermatology office visits None Preventive care/care/ screening/ immunization No charge $10 copay/office visit plus 20% coinsurance Member liability for Out-of-Network is based on services received. Charge; deductible does not apply Not covered You may have to pay for services that aren’t n't preventive. Ask your provider if the services you need needed are preventive. Then check what your plan will pay for. For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No charge Charge; deductible does not apply 20% coinsurance Preauthorization is recommended for certain services. None Imaging (CT/PET scans, MRIs) No charge Charge; deductible does not apply 20% coinsurance May require preauthorization If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1/xxx.xxxxx.xxx/xxxxxxxxx Generic or select prescribed over-the- counter drugs $5 copay/prescription (retail) copay for retail 30-day supply; $15 copay/prescription (mail5 copay for mail order 90-order) Not covered No charge for certain preventive drugs; Preauthorization is required for certain drugs; Infertility drugs: 20% coinsuranceday supply; deductible does not applyapply In-Network copay plus an additional 25% of the approved amount; deductible does not apply Preauthorization, step therapy and quantity limits may apply to select drugs. Tier 2/Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription drug program. Preferred brand brand-name drugs $20 copay/prescription (retail) 10 copay for retail 30-day supply; $60 copay/prescription (mail10 copay for mail order 90-order) Not covered Tier 3/Nonday supply; deductible does not apply In-preferred brand Network copay plus an additional 25% of the approved amount; deductible does not apply Nonpreferred brand-name drugs $30 copay/prescription (retail) 10 copay for retail 30-day supply; $90 copay/prescription (mail10 copay for mail order 90-order) Not covered Tier 4/Specialty drugs $30 copay/prescription (specialty pharmacy) 50day supply; deductible does not apply In-Network copay plus an additional 25% coinsurance of the approved amount; deductible does not apply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge Charge; deductible does not apply 20% coinsurance Preauthorization is recommended. None Physician/surgeon fees No Charge; deductible does not apply 20% coinsurance None Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) OutIn-of-Network Provider (You will pay the most) Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care $100 copay/visit $100 copay/visit; deductible does not apply Emergency room: Copay waived if admitted Air/Water Ambulance: No charge Urgent Care: Visit only; additional services received are subject to additional out-of-pocket costs. Emergency medical transportation $50 copay/trip $50 copay/trip; deductible does not apply Urgent care $10 copay/urgent care center visit $10 copay/urgent care center visit plus 20% coinsurance If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fees No charge 20% coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $10 copay/office visit No charge /outpatient services $10 copay/office visit plus 20% coinsurance 20% coinsurance /outpatient services Preauthorization is recommended for certain services. Inpatient services No charge 20% coinsurance If you are pregnant Office visits $10 copay/visit $10 copay/office visit plus20% coinsurance Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization is recommended. Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need immediate medical attention Emergency room care $50 copay/visit; deductible does not apply $50 copay/visit; deductible does not apply Copay waived if admitted or for an accidental injury. Emergency medical transportation No Charge; deductible does not apply No Charge; deductible does not apply Mileage limits apply Urgent care $10 copay/visit; deductible does not apply 20% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) No Charge; deductible does not apply 20% coinsurance Preauthorization is required Physician/surgeon fee No Charge; deductible does not apply 20% coinsurance None If you need behavioral health services (mental health and substance use disorder) Outpatient services No Charge; deductible does not apply No Charge; deductible does not apply for mental health; 20% coinsurance for substance use disorder Your cost share may be different for services performed in an office setting Inpatient services No Charge; deductible does not apply 20% coinsurance Preauthorization is required. If you are pregnant Office visits Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply Prenatal: 20% coinsurance Postnatal: 20% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound) and depending on the type of services cost share may apply. Cost sharing does not apply for preventive services. Childbirth/delivery professional services No Charge; deductible does not apply 20% coinsurance None Childbirth/delivery facility services No Charge; deductible does not apply 20% coinsurance None If you need help recovering or have other special health needs Home health care No charge Charge; deductible does not apply No Charge; deductible does not apply Physician certification required. Rehabilitation services No Charge; deductible does not apply 20% coinsurance None Rehabilitation Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Habilitation services No Charge; deductible does not apply for Applied Behavioral Analysis; No Charge; deductible does not apply for Physical, Speech and Occupational Therapy No Charge; deductible does not apply for Applied Behavioral Analysis; 20% coinsurance 20% coinsurance Includes for Physical, Speech and Occupational and Speech TherapyTherapy Applied behavioral analysis (ABA) treatment for Autism - when rendered by an approved board- certified behavioral analyst - is covered through age 18, subject to preauthorization. Physical and Occupational. Speech Therapy preauthorization is recommended for all visits. No Charge for services to treat autism spectrum disorder and preauthorization is not required Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care No charge 20% coinsurance Charge; deductible does not apply No Charge; deductible does not apply Preauthorization is recommendedrequired. Custodial Care is not covered. Limited to 120 days per member per calendar year Durable medical equipment 20% coinsurance 20% coinsurance Preauthorization is recommended for certain servicesNo Charge; deductible does not apply No Charge; deductible does not apply Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required. Hospice services No charge 20% coinsurance Preauthorization is recommendedCharge; deductible does not apply No Charge; deductible does not apply Physician certification required. Visit limits apply. If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator Children’s eye exam $10 copay/office visit $10 copay/office visit plus20% coinsurance Limited to one routine eye exam per year. Not covered Not covered None Children’s glasses Not covered Not covered None Children’s dental check-check- up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture treatment • Cosmetic surgery • Dental care (Adult) • Dental check-up, child Hearing aids • Glasses, child Infertility treatment • Long-Long term care • Routine eye care (Adult) • Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery surgery • Chiropractic care • Hearing aids • Infertility treatment • Most coverage Coverage provided outside the United States. Contact Customer Service for more information. See xxxx://xxxxxxxx.xxxx.xxx • Non-emergency care when traveling outside the U.S • Private-duty nursing • Routine eye care (Adult)Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit xxx.XxxxxxXxxx.xxx or call 0-000-000-0000.