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

Important Questions Answers Why This Matters. What is the overall deductible? For Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 8. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 8. See your policy or plan document for additional information about excluded services. •  Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. •  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. •  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) •  This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 07/01/2015 - 06/30/2017 06/30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 07/01/2015 - 06/30/2017 06/30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 20 copay per urgent care center visit $10 20 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 15 copay/office visit No Charge for outpatient services $10 15 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 15 copay/office visit No Charge for outpatient services $10 15 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 0 See the Common Medical Events chart below for an individual your costs for services this plan / $600 for a family plancovers. Doesn't apply to Are there services with a fixed dollar copay and prescription drugscovered before you meet your deductible? No. You must pay all the costs up will have to meet the deductible amount before this the plan begins to pay pays for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductibleany services. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see . What is the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers pocket limit for this plan? $6350 for an individual plan 1,500 Individual/$3,000 Family Prescription drug expense limit: $5,650 Individual / $12700 for a family plan. 11,300 Family The out-of-pocket limit is the most you could pay during in a coverage period (usually one year) year for your share of the cost of covered services. This 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 helps you plan for health care expenseshas been met. What is not included in the out–-of–-pocket limit? Premiums, balancebalanced-billed charges charges, and health care healthcare this plan doesn't n’t cover. Even though you pay these expenses, they don’t count toward the out-–of-–pocket limit. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will Will you pay for specific covered services, such as office visits. Does this plan less if you use a network of providersprovider? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx xxx.xxxxxx.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If 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 inout-of-network doctor or other health care provider, this and you might receive a xxxx from a provider for the difference between the provider’s charge and what your plan will pay some or all of the costs of covered servicespays (balance billing). Be aware, your in-network doctor or hospital may provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I you need a referral Referral to see a specialist? NoYes. You don't need referral This plan will pay some or all of the costs to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 8. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on but only if you have a Referral before you see the allowed amountspecialist. If Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an outIndependent Licensee of the Blue Cross and Blue Shield Association SBC IL HMO LG – 2017-of-network provider charges more than the allowed amount, you may have to pay the difference. For example2 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amountsa deductible applies. Common Medical Event Services You May Need Your cost if you use an In Network What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider Your cost if you use an Out(You will pay the least) Non-of-Network Participating Provider Limitations & Exceptions (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 per 15 copay/visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––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 copay per 15 copay/visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Not Covered Referral required. Preventive care/screening/screening/ immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability Not Covered You may have to pay for Out-of-Network is based on services received; For additional details, please see that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx will pay for. If you have a test Diagnostic test (x-ray, blood work) No Charge 20% coinsurance after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Not Covered Referral required. Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended Not Covered Referral required. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxxwww.express- xxxxxxx.xxx or 800-711- 0917. Tier 1 generally low cost generic Generic drugs 10% / retail or mail order Not Covered Retail 30 day supply; up to $5 copay per prescription (retail) 1,500 individual / $15 copay per prescription (mail- order) 2,500 family Mail order 90 day supply up to $1,500 individual / $2,500 family RX Out-of-Pocket Expense Limit: $5,650 Individual / $11,300 Family Prior authorization may be required. Preferred brand drugs 15% / retail or mail order Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and Covered Non-preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain / retail or mail order Not Covered Specialty drugs 15% / retail or mail order Not Covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Not Covered Referral required. Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete listReferral required. Check your * For more information about limitations and exceptions, see the plan or policy or plan document for other excluded servicesat xxx.xxxxxx.xxx/xxxxxx/xxxxxx-xxxxx.) • 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of$350/single,$700/family Network $500/single,$1,000/family Non-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay co-insurance, copays and prescription drugs. network preventive care You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. No You don’t have to meet deductibles for specific services, but see the chart starting on page 3 2 for other costs for services this plan covers. Is there an out–-of–-pocket limit on my expenses? Yes. For In , $1,000/single,$2,000/family Network providers $6350 for an individual plan / 3,500/single, $12700 for a 7,000/family plan. For Out-ofNon-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–-of–-pocket limit? PremiumsCopays, deductibles, premiums, balance-billed 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. Is there an overall annual limit on what the plan insurer pays? No. No The chart starting on page 3 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx XxxXxxxxx.xxx/XXX or call 0-000-000-0000 or (000) 000-0000 000.000.0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 2 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. No You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t n't cover? Yes. Yes Some of the services this plan doesn’t cover are listed on page 8later in the document. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 07/01/2015 - 06/30/2017 06/30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. •  Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. •  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. •  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) •  This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 07/01/2015 - 06/30/2017 06/30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. •  Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. •  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. •  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) •  This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 20 copay per visit $10 20 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 20 copay per visit $10 20 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/immunization No Charge $10 20 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; $75 maximum charge per prescription (except infertility drugs); Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 20 copay per urgent care center visit $10 20 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 20 copay/office visit No Charge for outpatient services $10 20 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 20 copay/office visit No Charge for outpatient services $10 20 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 20 copay $10 20 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 07/01/2015 - 06/30/2017 06/30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. •  Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. •  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. •  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) •  This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 20 copay per urgent care center visit $10 20 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 15 copay/office visit No Charge for outpatient services $10 15 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 15 copay/office visit No Charge for outpatient services $10 15 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. •  Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. •  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. •  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) •  This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 20 copay per visit $10 20 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 20 copay per visit $10 20 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/immunization No Charge $10 20 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; $75 maximum charge per prescription (except infertility drugs); Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 20 copay per urgent care center visit $10 20 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 20 copay/office visit No Charge for outpatient services $10 20 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 20 copay/office visit No Charge for outpatient services $10 20 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 20 copay $10 20 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. •  Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. •  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. •  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) •  This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 20 copay per urgent care center visit $10 20 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 15 copay/office visit No Charge for outpatient services $10 15 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 15 copay/office visit No Charge for outpatient services $10 15 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-$250/single,$500/family HMO Network providers $200 for an individual plan / $600 for a N/A/single, N/A/family plan. Non- HMO Network Doesn't apply to services with a fixed dollar copay coinsurance, copays and prescription drugs. network preventive care You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. No You don’t have to meet deductibles for specific services, but see the chart starting on page 3 2 for other costs for services this plan covers. Is there an out–-of–-pocket limit on my expenses? Yes. For In , Coinsurance Limit: $0/single, $0/family HMO Network providers $6350 for an individual plan / $12700 for a N/A/single, N/A/family plan. For Non-HMO Network Out-of-pocket Limit: $1,000/single,$3,000/family HMO Network providers $6350 for an individual plan / $12700 for a N/A/single, N/A/family plan. Non-HMO Network The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. The coinsurance limit is included in the out-of-pocket limit. What is not included in the out–-of–-pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan insurer pays? No. No The chart starting on page 3 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx XxxXxxxxx.xxx/XXX or call 0-000-000-0000 or (000) 000-0000 000.000.0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 2 for how this plan pays different kinds of providers. HealthMate CoastQuestions: Call 000.000.0000 or visit us at XxxXxxxxx.xxx/XXX. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a copy. 848559999 BEN1616651442206-to-Coast 00004 Medical Health Ins. Corp: Plan 1 Coverage Period: 07/01/2016 06/01/2016 - 06/30/2017 05/31/2017 Summary of and Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Single or Family | Plan Type: PPO HMO Do I need a referral to see a specialist? No. You don't Yes, you need referral written approval to see a specialist. You can non-network provider, except for ER This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist you choose without permission from this planspecialist. Are there services this plan doesn’t n't cover? Yes. Yes Some of the services this plan doesn’t cover are listed on page 86. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s 's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t n't met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network Authorized providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Cost If You Use HMO Network Provider Your cost if you use an OutCost If You Use Non-of-HMO Network Provider Limitations & Exceptions and Exclusions If you visit a health care provider’s 's office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit (Chiropractic) Other practitioner office visit (Acupuncture) Preventive care/ screening/ immunization $10 copay per copay/visit $20 copay/visit $10 copay plus 20% coinsurance after deductible per copay/visit Chiropractic Services are limited to 12 Not Covered No charge Not Covered Not Covered Not Covered Not Covered Not Covered none none (30 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx benefit period) Excluded Service none If you have a test Diagnostic test (x-ray, ) Diagnostic test (blood work) No Charge 20% coinsurance after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance charge after deductible Preauthorization is recommended No charge after deductible No charge after deductible Not Covered Not Covered Not Covered none none none Questions: Call 000.000.0000 or visit us at XxxXxxxxx.xxx/XXX. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a copy. 848559999 BEN1616651442206-00004 Medical Health Ins. Corp: Plan 1 Coverage Period: 06/01/2016 - 05/31/2017 Summary and Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single or Family | Plan Type: HMO Common Medical Event Services You May Need Your Cost If You Use HMO Network Your Cost If You Use Non-HMO Network Limitations and Exclusions If you need drugs to treat your illness or condition Generic copay - retail /Rx Generic copay - home delivery /Rx Brand Name copay - retail /Rx $5 $5 $15 Does Not Apply Does Not Apply Does Not Apply Covers up to a 30-day supply. Covers up to a 90-day supply. Covers up to a 30-day supply. More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic XxxXxxxxx.xxx/XXX Brand Name copay - home delivery /Rx Specialty drugs $5 copay per prescription (retail) – retail Specialty drugs - home delivery $15 copay per prescription (mail- order) $15 $15 Does Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Apply Does Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Apply Does Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs Apply Covers up to a 90-day supply. Covers up to a 30-day supply Covers up to a 30-day supply If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees (Outpatient) No Charge 20% coinsurance charge after deductible –––––––––––none––––––––––– $10 copay/visit Not Covered Not Covered -------- none------- ----------none------- If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted services| Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center 75 copay/visit $10 copay plus 20% coinsurance after deductible per urgent care center 50 copay/visit Applies to the $35 copay/visit only. If additional services are provided additional out of pockets costs would apply based on services received. Not Covered Not Covered Not Covered ----------none------- ----------none------- ----------none------- If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee (inpatient) No Charge 20% coinsurance charge after deductible –––––––––––none––––––––––– No charge after deductible Not Covered Not Covered ----------none------- ----------none------- Questions: Call 000.000.0000 or visit us at XxxXxxxxx.xxx/XXX. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a copy. 848559999 BEN1616651442206-00004 Medical Health Ins. Corp: Plan 1 Coverage Period: 06/01/2016 - 05/31/2017 Summary and Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single or Family | Plan Type: HMO Common Medical Event Services You May Need Your cost if you use an In Cost If You Use HMO Network Provider Your cost if you use an OutCost If You Use Non-of-HMO Network Provider Limitations & Exceptions and Exclusions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for (alcoholism) Substance use disorder outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for (drug use) Substance use disorder outpatient services Preauthorization is recommended for certain services (drug use) Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended (drug use) $10 copay/visit Benefits paid based on corresponding medical benefits $10 copay/visit $10 copay/visit Benefits paid based on corresponding medical benefits Benefits paid based on corresponding medical benefits Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered ----------none------- ----------none------- ----------none------- ----------none------- ----------none------- ----------none------- If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance charge after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an OutNo charge after deductible Not Covered Not Covered (Prenatal Visits are covered at no charge with in-of-Network Provider Limitations & Exceptions network providers) none If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, (Physical Therapy) Habilitation services (Occupational and Therapy) Habilitation services (Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. ) Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance charge after deductible Preauthorization is recommended No charge after deductible $10 copay/visit $10 copay/visit No charge after deductible No charge No charge after deductible Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered none (30 visits per benefit period) (30 visits per benefit period) (30 visits per benefit period) (100 days per benefit period) none none Questions: Call 000.000.0000 or visit us at XxxXxxxxx.xxx/XXX. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a copy. 848559999 BEN1616651442206-00004 Medical Health Ins. Corp: Plan 1 Coverage Period: 06/01/2016 - 05/31/2017 Summary and Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single or Family | Plan Type: HMO Common Medical Event Services You May Need Your Cost If You Use HMO Network Your Cost If You Use Non-HMO Network Limitations and Exclusions If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. (Child) Glasses Dental check-up (Child) No charge Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Not Covered none Excluded Service Excluded Service Questions: Call 000.000.0000 or visit us at XxxXxxxxx.xxx/XXX. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a copy. 848559999 BEN1616651442206-00004 Medical Health Ins. Corp: Plan 1 Coverage Period: 06/01/2016 - 05/31/2017 Summary and Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single or Family | Plan Type: HMO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t n't a complete list. Check your policy or plan document for other excluded services.) • Acupuncture • Cosmetic surgery Surgery • Dental care check-up (Child) • Dental Care (Adult) • Dental check-up, child Glasses • Glasses, child Hearing Aids • Long-term Term Care • Non-emergency care when traveling outside the U.S. • Private-Duty Nursing • Routine foot care unless to treat a systemic condition Eye Care (Adult) • Routine Foot Care • Weight loss programs Loss Programs Other Covered Services (This isn’t n't a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. •  Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. •  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. •  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) •  This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 20 copay per urgent care center visit $10 20 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 15 copay/office visit No Charge for outpatient services $10 15 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 15 copay/office visit No Charge for outpatient services $10 15 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 $500 Person / $1,500 Family For Out-of-Network providers $200 for an individual plan 1,000 Person / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. 3,000 Family You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 2 for how much you pay for covered services after you meet the deductible. Yes. $150 deductible for In- Network hospital admission. Are there other deductibles for specific services? No$150 deductible for Out-of- Network hospital admission. There are no other specific deductibles. You don’t have to meet deductibles for specific services, but see must pay all of the chart starting on page 3 for other costs for these services up to the specific deductible amount before this plan coversbegins to pay for these services. Is there an out–of–– pocket limit on my expenses? Yes. For In In-Network providers $6350 for an individual plan 3,000 Person / $12700 for a family plan. 9,000 Family For Out-of-Network providers $6350 for an individual plan 6,000 Person / $12700 for a family plan. 18,000 Family The out-of-pocket limit pocketlimit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? PremiumsPrescription copay, balancepremiums, balanced-billed charges charges, 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits–pocketlimit. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx Visit xxx.xxxxxx.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating In-Network providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 2 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 85. See your policy or plan document for additional information about excluded servicesexcludedservices. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billingbalancebilling.) • This plan may encourage you to use In In-Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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) Imaging (CT/PET scans, MRIs) Your Cost If You Use an In-Network Provider $20 copay/visit plus 10% coinsurance $40 copay/visit plus 10% coinsurance 10% coinsurance No Charge 20$100 copay/visit 10% coinsurance after deductible Preauthorization $100 copay/visit 10% coinsurance Your Cost If You Use an Out-of-Network Provider $20 copay/visit plus 30% coinsurance $40 copay/visit plus 30% coinsurance 30% coinsurance 30% coinsurance $100 copay/visit 30% coinsurance $100 copay/visit 30% coinsurance Limitations & Exceptions Copay applies to office visit only. Chiropractic services are limited to 15 visits per calendar year. Deductible is recommended waived for certain services preventive care Out-of-Network. ---none--- ---none--- Common Medical Event Services You May Need Your cost if you use Cost If You Use an In In-Network Provider Your cost if you use Cost If You Use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scansGeneric drugs Retail - $10 copay Mail - $20 copay Same as In-Network Certain women’s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended please contact Customer Service. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxxxxx.xxxxxxxx.xxx 0-000-000-0000 Formulary brand drugs Retail - $35 copay Mail - $70 copay Same as In-Network Up to 34 day retail / 90 day mail. Tier 1 generally low cost generic In-Network RX Out-of-Pocket Expense Limit: $2,500 Individual $5,000 Family Non-Formulary brand drugs Retail - $5 50 copay per prescription (retail) Mail - $15 100 copay per prescription (mail- order) Same as In-Network Specialty drugs Covered Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 Covered Certain specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs medications must be obtained through the CVS/Caremark Specialty Pharmacy. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20$100 copay plus 10% coinsurance after deductible Preauthorization is recommended $100 copay plus 30% coinsurance ---none--- Physician/surgeon fees No Charge 2010% coinsurance after deductible –––––––––––none––––––––––– 30% coinsurance ---none--- If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted 10% coinsurance 10% coinsurance ---none--- Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent 20% coinsurance ---none--- Urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. 10% coinsurance 30% coinsurance ---none--- If you have a hospital stay Facility fee (e.g., hospital room) No Charge 2010% coinsurance after 30% coinsurance $150 inpatient deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended applies before coinsurance. Physician/surgeon fee No Charge 2010% coinsurance after deductible –––––––––––none––––––––––– 30% coinsurance ---none--- Common Medical Event Services You May Need Your cost if you use Cost If You Use an In In-Network Provider Your cost if you use Cost If You Use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 20 copay/office visit No Charge for outpatient services $10 copay plus 2010% coinsurance after deductible$20 copay/office visit 20plus 30% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services PCP copay applies to psychotherapy visit only. Mental/Behavioral health inpatient services No Charge 2010% coinsurance after 30% coinsurance $150 inpatient deductible Preauthorization is recommended applies before coinsurance. Substance use disorder outpatient services $10 20 copay/office visit No Charge for outpatient services $10 copay plus 2010% coinsurance after deductible$20 copay/office visit 20plus 30% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services PCP copay applies to psychotherapy visit only. Substance use disorder inpatient services No Charge 2010% coinsurance after 30% coinsurance $150 inpatient deductible Preauthorization is recommended applies before coinsurance. If you are pregnant Prenatal and postnatal care No Charge 20$20 copay/visit plus 10% coinsurance after deductible –––––––––––none––––––––––– $20 copay/visit plus 30% coinsurance Copay applies to first prenatal visit (per pregnancy). Delivery and all inpatient services No Charge 2010% coinsurance after 30% coinsurance $150 inpatient deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions applies before coinsurance. If you need help recovering or have other special health needs Home health care No Charge 2010% coinsurance after deductible –––––––––––none––––––––––– 30% coinsurance Limited to 40 visits per benefit period. Rehabilitation services 2010% coinsurance 2030% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative ---none--- Habilitation services 2010% coinsurance 2030% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. ---none--- Skilled nursing care No Charge 2010% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered 30% coinsurance ---none--- Durable medical equipment 2010% coinsurance 2030% coinsurance after deductible Preauthorization is recommended Benefits are limited to items used to serve a medical purpose. DME benefits are provided for certain servicesboth purchase and rental equipment (up to the purchase price). Hospice service No Charge 2010% coinsurance after deductible Preauthorization is recommended 30% coinsurance ---none--- If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Not Covered Not Covered ---none--- Glasses Not Covered Not Covered –––––––––––none––––––––––– ---none--- Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 ---none--- Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • Bariatric Surgery • Chiropractic care • Hearing aids • Care Infertility treatment • Treatment Most coverage provided outside the Non-Emergency Care When Traveling Outside the U.S. Private Duty Nursing (with the exception o inpatient private duty nursing) United States. Contact Customer Service See xxx.xxxxxx.xxx Hearing Aids Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excludedservices.) Acupuncture Dental Care (Adult and Children) Routine Eye Care (Adult and Children) Routine Foot Care (with the exception of Cosmetic Surgery Long Term Care person with diagnosis of diabetes) Weight Loss Program Excluded Services & Other Covered Services: Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more informationinformation on your rights to continue coverage, contact the plan at 0-000-000-0000. • PrivateYou may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 0-duty nursing • Routine eye care (Adult)000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx.

Important Questions Answers Why This Matters. What is the overall deductible? For Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need a referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t n't cover are listed on page 85. See your policy or plan document for additional information about excluded services. • Copayments Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for of the service. For example, if the health plan’s 's allowed amount for an overnight hospital stay is $1,000, your coinsurance co-insurance payment of 20% would be $200. This may change if you haven’t n't met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges charge is $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network in-network providers by charging you lower deductibles, copayments co-payments and coinsurance co-insurance amounts. Are there services this plan doesn't cover? Common Medical Event Services You May Need Your cost if you use an In In-Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s 's office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus No charge after plan deductible 20% coinsurance co-insurance after plan deductible per visit –––––––––––........... none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of$250/single,$500/family Network $500/single,$1,000/family Non-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay coinsurance, copays and prescription drugs. network preventive care You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. No You don’t have to meet deductibles for specific services, but see the chart starting on page 3 2 for other costs for services this plan covers. Is there an out–-of–-pocket limit on my expenses? Yes. For In , Coinsurance Limit: $1,000/single,$2,000/family Network providers $6350 for an individual plan / $12700 for a 2,000/single,$4,000/family plan. For Non-Network Out-of-pocket Limit: $6,600/single,$13,200/family Network providers $6350 for an individual plan / $12700 for a Unlimited/single,Unlimited/family plan. Non-Network The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. The coinsurance limit is included in the out-of-pocket limit. What is not included in the out–-of–-pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan insurer pays? No. No The chart starting on page 3 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx XxxXxxxxx.xxx/XXX or call 0-000-000-0000 or (000) 000-0000 000.000.0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 2 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. No You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 8. Yes See your policy or plan document for additional information about excluded services. • Copayments Questions: Call 000.000.0000 or visit us at XxxXxxxxx.xxx/XXX. If you aren’t clear about any of the underlined terms in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a copy. 882859801 BEN1611683108853-00020 APPENDIX M (continued) LERC : Plan 6 Vermilion Coverage Period: 07/01/2016 – 06/30/2017 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Single or Family / Plan Type: PPO •Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance •Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s 's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t n't met your deductible. • The •The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This •This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost Cost if you use an In You Use a Network Provider Your cost Cost if you use an Out-ofYou Use a Non-Network Provider Limitations & and Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per 15 copay/visit $10 copay plus 2030% coinsurance after deductible per visit –––––––––––none––––––––––– -----none----- Specialist visit $10 copay per 15 copay/visit $10 copay plus 2030% coinsurance after deductible per visit –––––––––––none––––––––––– -----none----- Other practitioner office visit $10 copay per visit $10 copay plus 20(Chiropractic) 10% coinsurance after deductible per 30% coinsurance -----none----- Other practitioner office visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits (Acupuncture) Not Covered Excluded Service Preventive care/screening/care / screening / immunization No Charge $10 copay plus 20charge 50% coinsurance after deductible Member liability for Out-of-Network is based on services received; For additional details, please see your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx -----none----- If you have a test Diagnostic test (x-ray, ) 10% coinsurance 30% coinsurance -----none----- Diagnostic test (blood work) No Charge 2010% coinsurance after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions 30% coinsurance -----none----- Imaging (CT/PET scans, MRIs) No Charge 2010% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 5030% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs -----none----- If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 2010% coinsurance after deductible Preauthorization is recommended 30% coinsurance -----none----- Physician/surgeon fees No Charge 20(Outpatient) 10% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 2030% coinsurance after deductible per urgent care center -----none----- Questions: Call 000.000.0000 or visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services receivedus at XxxXxxxxx.xxx/XXX. If you have aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization copy. 882859801 BEN1611683108853-00020 APPENDIX N LERC : Plan 21 Coverage Period: 07/01/2016 – 06/30/2017 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Single or Family / Plan Type: PPO This is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions only a summary. If you have mental healthwant more detail about your coverage and costs, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a can get the complete list. Check your terms in the policy or plan document for other excluded servicesat XxxXxxxxx.xxx/XXX or by calling 800.521.6492.) • 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 for an individual plan / 1,000 Individual $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. 2,000 Family You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 2 for how much you pay for covered services after you meet the deductible. Are there other Yes. $300 deductible for Out- of-Network hospital admission. You must pay all of the costs for these services up to the specific deductible amount deductibles for specific services? NoThere are no other specific deductibles. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services before this plan coversbegins to pay for these services. Is there an out–of–– pocket limit on my expenses? Yes. For In In-Network providers $6350 for an individual plan / 3,000 Individual $12700 for a family plan. 6,000 Family For Out-of-Network providers $6350 for an individual plan / 6,000 Individual $12700 for a family plan. 12,000 Family The out-of-pocket limit pocketlimit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balancebalanced-billed charges charges, 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits–pocketlimit. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx Visit xxx.xxxxxx.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating In-Network providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 2 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 84. See your policy or plan document for additional information about excluded servicesexcludedservices. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an outQuestions: Call 0-of000-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out000-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; For additional details, please see your plan documents 0000 or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No Charge 20% coinsurance after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available us at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded servicesxxx.xxxxxx.xxx.) • 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of$3,750/single,$7,500/family Network $4,000/single,$8,000/family Non-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay coinsurance, copays and prescription drugs. network preventive care You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. No You don’t have to meet deductibles for specific services, but see the chart starting on page 3 2 for other costs for services this plan covers. Is there an out–-of–-pocket limit on my expenses? Yes. For In , Coinsurance Limit: $2,250/single,$4,500/family Network providers $6350 for an individual plan / $12700 for a 10,000/single,$20,000/family plan. For Non-Network Out-of-pocket Limit: $6,600/single,$13,200/family Network providers $6350 for an individual plan / $12700 for a 14,000/single,$28,000/family plan. Non-Network The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. The coinsurance limit is included in the out-of-pocket limit. What is not included in the out–-of–-pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan insurer pays? No. No The chart starting on page 3 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx XxxXxxxxx.xxx/XXX or call 0-000-000-0000 or (000) 000-0000 000.000.0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 2 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. No You can see the specialist you choose without permission from this plan. plan Are there services this plan doesn’t cover? Yes. Yes Some of the services this plan doesn’t cover are listed on page 85. See your policy or plan document for additional information about excluded services. • Copayments Questions: Call 000.000.0000 or visit us at XxxXxxxxx.xxx/XXX. If you aren’t clear about any of the underlined terms in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a copy. 882859134 CMS1611300000620-01927 APPENDIX N (continued) LERC : Plan 21 Coverage Period: 07/01/2016 – 06/30/2017 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Single or Family / Plan Type: PPO •Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance •Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s 's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t n't met your deductible. • The •The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This •This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost Cost if you use an In You Use a Network Provider Your cost Cost if you use an Out-ofYou Use a Non-Network Provider Limitations & and Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per 50 copay/visit $10 copay plus 2050% coinsurance after deductible per visit –––––––––––none––––––––––– -----none----- Specialist visit $10 100 copay per visit $10 copay plus 2050% coinsurance after deductible per visit –––––––––––none––––––––––– -----none----- Other practitioner office visit $10 copay per visit $10 copay plus 20(Chiropractic) 30% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 2050% coinsurance after deductible Member liability for Out-of-Network is based on services received; For additional details, please see your plan documents or -----none----- Other practitioner office visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx (Acupuncture) Not Covered Excluded Service Preventive care / screening / immunization 30% coinsurance 50% coinsurance -----none----- If you have a test Diagnostic test (x-ray, ) 30% coinsurance 50% coinsurance -----none----- Diagnostic test (blood work) No Charge 2030% coinsurance after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions 50% coinsurance -----none----- Imaging (CT/PET scans, MRIs) No Charge 2030% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs-----none----- Questions: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per Call 000.000.0000 or visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services receivedus at XxxXxxxxx.xxx/XXX. If you have aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at XxxXxxxxx.xxx/XXX or call 000.000.0000 to request a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Outcopy. 882859134 APPENDIX O Pre- and Post-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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)Conference Questions Ohio Teacher Evaluation System

Important Questions Answers Why This Matters. What is the overall deductible? For Out-of-Network providers $200 for an individual plan / $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 07/01/2015 - 06/30/2017 06/30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 87. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 15 copay per visit $10 15 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 20 copay per visit $10 20 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 20 copay per visit $10 20 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits year Preventive care/screening/immunization No Charge $10 20 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay 20% coinsurance per prescription (retail) $15 copay per prescription (mail- /mail-order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay 20% coinsurance per prescription (retail) $60 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay 20% coinsurance per prescription (retail) $90 copay per prescription (mail- /mail-order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay 20% coinsurance per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; $75 maximum charge per prescription (except infertility drugs); Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 75 copay per visit $100 75 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 20 copay per urgent care center visit $10 20 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 20 copay/office visit No Charge for outpatient services $10 20 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 20 copay/office visit No Charge for outpatient services $10 20 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 20 copay $10 20 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Out-of-Network providers $200 0 See the Common Medical Events chart below for an individual plan / $600 your costs for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covers. Are there services covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after before you meet the your deductible. ? Not Applicable Not Applicable Are there other deductibles for specific services? No. No You don’t n't have to meet deductibles for specific services, but see . What is the chart starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / $12700 for a family plan. For Out-of-Network providers pocket limit for this plan? $6350 for an individual plan / 6,850/Member and $12700 for a family plan. 13,700/Family The out-of-pocket limit is the most you could pay during in a coverage period (usually one year) year for your share of the cost of covered services. This 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 helps you plan for health care expenseshas been met. What is not included in the out–-of–-pocket limit? PremiumsPenalties for not obtaining any required prior authorization, premiums, balance-billed charges 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-of- pocket limit. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will Will you pay for specific covered services, such as office visits. Does this plan less if you use a network of providersprovider? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx xxx.xxxxxxxxxxxxxxxxxx.xxx/Xxxxxx/Xxxxxx- or-Provider or call 0-000-000-0000 or (000) 000-0000 for a list of participating providersPlan Providers. If 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 inout-of-network doctor or other health care provider, this and you might receive a bill from a provider for the difference between the provider's charge and what your plan will pay some or all of the costs of covered servicespays (balance billing). Be aware, aware your in-network doctor or hospital may provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I you need a referral to see a specialist? No. You don't need referral Yes This plan will pay some or all of the costs to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 8. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on but only if you have a referral before you see the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amountsspecialist. Common Medical Event Services You May Need Your cost if you use an In Network What You Will Pay Limitations, Exceptions & Other Important Information HMO Provider Your cost if you use an Out(You will pay the least) Non-of-Network Plan Provider Limitations & Exceptions (You will pay the most) If you visit a health care provider’s 's office or clinic Primary care visit to treat an injury or illness $10 copay per 20 copay/visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Not Covered None Specialist visit $10 copay per 40 copay/visit Not Covered Member pays for cost of services if prior authorization is not obtained. Plan Providers seen without a referral $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits 50 copay/visit. Preventive care/screening/care/ screening/ immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability charge Not Covered You may have to pay for Out-of-Network is based on services received; For additional details, please see that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan documents or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx will pay for. If you have a test Diagnostic test (x-ray, blood work) No Charge 20% coinsurance after deductible Preauthorization X-ray: $5 copay/service Lab: $5 copay/service Not Covered Member pays for cost of services if prior authorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions not obtained. Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended PET Scan: $10 copay/service MRI: $10 copay/service CT: $10 copay/service Not Covered If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. www.healthplanofnevada .com Tier 1 generally low cost generic drugs $5 copay per 25 copay/prescription (retail) $15 copay per 62.50 copay/prescription (mail- ordermail) Not covered No Charge Covered You have a 3-Tier pharmacy plan. Covers up to a 30-day retail supply or up to a 90-day mail order supply. Member pays for certain preventive drugs cost of services if prior authorization or step therapy is not obtained. Tier 2 generally high cost generic and preferred brand name drugs $20 copay per 50 copay/prescription (retail) $60 copay per 125 copay/prescription (mail- ordermail) Not covered Preauthorization is required for certain drugs Covered Tier 3 non- preferred brand name drugs $30 copay per 75 copay/prescription (retail) $90 copay per 187.50 copay/prescription (mail- ordermail) Not covered Preauthorization is required for certain drugs Covered Tier 4 specialty prescription drugs $30 copay per prescription Not Covered Not Covered Not Applicable. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information HMO Provider (specialty pharmacy onlyYou will pay the least) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs Non-Plan Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization $75 copay/admit Not Covered Member pays for cost of services if prior authorization is recommended not obtained. Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– $20 copay/surgery Not Covered If you need immediate medical attention Emergency room services care ER Physician: No charge ER Facility: $100 copay per 500 copay/visit ER Physician: No charge ER Facility: $100 copay per 500 copay/visit Copay waived if admitted You may be balance billed from Non-Plan Providers. Emergency medical transportation $50 copay per copay/trip $50 copay per copay/trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center 20 copay/visit $10 copay plus 20% coinsurance after deductible per urgent care center 20 copay/visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services receivedYou may be balance billed from Non-Plan Providers. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 $350 copay/day limit at an inpatient rehabilitation facility; Preauthorization $1750 max/admit Not Covered Member pays for cost of services if prior authorization is recommended not obtained. Physician/surgeon fee fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions charge Not Covered If you have need mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services Outpatient services $10 copay/office visit No Charge Not Covered Member pays for outpatient cost of services if prior authorization is not obtained. Inpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 350 copay/office visit No Charge for outpatient services day $10 copay plus 20% coinsurance after deductible1750 max/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended admit Not Covered If you are pregnant Prenatal Office visits No charge Not Covered Routine prenatal care obtained from a Plan Provider is covered at no charge. Maternity care may include tests and postnatal care services described elsewhere in the SBC (i.e. Lab). Childbirth/delivery professional services Surgical: No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery charge Anesthesia: No charge Not Covered Childbirth/delivery professional services includes Anesthesia and all inpatient Physician Surgical Services; each service has a separate cost- share. Member pays for cost of services No Charge 20% coinsurance after deductible Preauthorization if prior authorization is recommended not obtained. Childbirth/delivery facility services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is not obtained. Common Medical Event Services You May Need Your cost if you use an In Network What You Will Pay Limitations, Exceptions & Other Important Information HMO Provider Your cost if you use an Out(You will pay the least) Non-of-Network Plan Provider Limitations & Exceptions (You will pay the most) If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– charge Not Covered Does not include Specialty Prescription Drugs. Member pays for cost of services if prior authorization is not obtained. Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational $5 copay/visit Not Covered Coverage is limited to a combined Inpatient and Speech TherapyOutpatient benefit of 120 days/visits per year. Speech Therapy preauthorization Member pays for cost of services if prior authorization is recommended not obtained. Habilitation services $5 copay/visit Not Covered Coverage is limited to a combined Inpatient and Outpatient benefit of 120 days/visits per year. Member pays for all visits. Habilitative cost of services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization if prior authorization is recommended for all visitsnot obtained. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization $250 copay/admit Not Covered Coverage is recommended; Custodial Care limited to 100 days. Member pays for cost of services if prior authorization is not covered obtained. Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization No charge Not Covered For purchase or rental at HPN's option. Purchases are limited to a single type of DME, including repair and replacement, every 3 years. Member pays for cost of services if prior authorization is recommended for certain servicesnot obtained. Hospice service No Charge 20% coinsurance after deductible Preauthorization services $350 copay/day $1750 max/admit Not Covered Member pays for cost of services if prior authorization is recommended not obtained. If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine Children's eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental Your plan may include certain vision and/or dental services. Please refer to your plan documents for more information. Children's glasses Not Covered Not Covered Children's dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (This isn’t a complete list. Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Abortion (except for rape, incest, life at risk) Dental care (Adult) • Dental check-up, child • Glasses, child • Routine eye care (Adult) Acupuncture 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. Check Please see your policy or plan document for other covered services and your costs for these servicesdocument.) • Bariatric Surgery • Chiropractic care • surgery - One (1) per Lifetime Hearing aids • Infertility treatment • Most coverage provided outside the United States. Contact Customer Service for more information. • - One (1) every three (3) years (including Private-duty nursing • Routine eye repair/replace) Chiropractic care - 20 visits per calendar year Limited infertility treatment Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. For group health coverage subject to ERISA, contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. 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. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx or the Nevada Department of Insurance at 000-000-0000 or xxx.xxx.xx.xxx or call 0-000-000-0000 Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet Minimum Value Standards? Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. ---------------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section----------------------------------- About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx's type 2 diabetes (a year of routine in-network care of a well-controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible Specialist copayment Hospital (facility) copayment Other copayment $0.00 $40.00 $350.00 $0.00 The plan's overall deductible Specialist copayment Hospital (facility) copayment Other copayment $0.00 $40.00 $125.00 $5.00 The plan's overall deductible Specialist copayment Hospital (facility) copayment Other copayment $0.00 $40.00 $125.00 $5.00 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) $12,700.00 Total Example Cost Cost Sharing Deductibles $0.00 Copayments $900.00 Coinsurance $100.00 What isn't covered Limits or exclusions $0.00 The total Peg would pay is $1,000.00 In this example, Peg would pay: This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) $7,400.00 Total Example Cost Cost Sharing Deductibles $0.00 Copayments $2,000.00 Coinsurance $0.00 What isn't covered Limits or exclusions $0.00 The total Xxx would pay is $2,000.00 In this example, Xxx would pay: This EXAMPLE event includes services like: Emergency room care (Adult)including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) $1,900.00 Total Example Cost Cost Sharing Deductibles $0.00 Copayments $600.00 Coinsurance $0.00 What isn't covered Limits or exclusions $0.00 The total Mia would pay is $600.00 In this example, Xxx would pay:

Important Questions Answers Why This Matters. What is the overall deductible? For Out-of-Network providers $200 for an individual plan / 2,500 Individual $600 for a family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. 5,000 Family You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 2 for how much you pay for covered services after you meet the deductible. Are there other Yes. $300 deductible for Out- deductibles for specific services? Noof-Network hospital admission. There are no other specific deductibles. You don’t have to meet deductibles for specific services, but see must pay all of the chart starting on page 3 for other costs for these services up to the specific deductible amount before this plan coversbegins to pay for these services. Is there an out–of–– pocket limit on my expenses? Yes. For In Network providers $6350 for an individual plan / 5,000 Individual $12700 for a family plan. For Out-of-Network providers $6350 for an individual plan / $12700 for a family plan. 10,000 Family The out-of-pocket limit pocketlimit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balancebalanced-billed charges charges, 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. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits–pocketlimit. Does this plan use a network of providers? Yes, this plan uses in-network providers. See xxx.XXXXXX.xxx Visit xxx.xxxxxx.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating In-Network providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 2 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 85. See your policy or plan document for additional information about excluded servicesexcludedservices. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an outQuestions: Call 0-of000-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out000-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Specialist visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit –––––––––––none––––––––––– Other practitioner office visit $10 copay per visit $10 copay plus 20% coinsurance after deductible per visit Chiropractic Services are limited to 12 visits per year; $15 copay for allergy and dermatology office visits Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; For additional details, please see your plan documents 0000 or visit xxx.XXXXXX.xxx/xxxxxxxxx/xxxxxxxx If you have a test Diagnostic test (x-ray, blood work) No Charge 20% coinsurance after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available us at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible –––––––––––none––––––––––– If you need immediate medical attention Emergency room services $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) No Charge 20% coinsurance after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care No Charge 20% coinsurance after deductible –––––––––––none––––––––––– Rehabilitation services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Habilitative services 20% coinsurance 20% coinsurance after deductible Includes Physical, Occupational and Speech Therapy. Speech Therapy preauthorization is recommended for all visits. Skilled nursing care No Charge 20% coinsurance after deductible Preauthorization is recommended; Custodial Care is not covered Durable medical equipment 20% coinsurance 20% coinsurance after deductible Preauthorization is recommended for certain services. Hospice service No Charge 20% coinsurance after deductible Preauthorization is recommended If your child needs dental or eye care Eye exam $10 copay $10 copay plus 20% coinsurance after deductible Limited to one routine eye exam per year. Glasses Not Covered Not Covered –––––––––––none––––––––––– Dental check-up Not Covered Not Covered –––––––––––none––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded servicesxxx.xxxxxx.xxx.) • 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 (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • 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 Outin-network providers Deductible is not applicable in- network For out-of-Network network providers $200 for an 500 individual plan / $600 for a 1,000 2-person $1,000 family plan. Doesn't apply to services with a fixed dollar copay and prescription drugs. You must pay all the costs up to the deductible amount before this plan begins to pay for covered out-of-network services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 26 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 26 for other costs for services this plan covers. Is there an out–of–pocket limit on my expenses? Yes. For In Network providers in-network providers: $6350 for an 6,350 individual plan / $12700 for a 12,700 family plan. For Outout-of-Network providers network providers: $6350 for an 1,000 individual plan / $12700 for a 1,750 2-person $1,750 family plan. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of out-of-network covered services. This limit helps you plan for health care expenses. What is not included in the out–of–pocket limit? Premiums, balance-billed charges charges, and health care this plan doesn't n’t cover. Even though you pay these expenses, they don’t count toward the out-of-of- pocket limit. Is there an overall annual limit on what the plan pays? No. The chart starting on page 3 26 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. For a list of preferred providers, this plan uses in-network providers. See xxx.XXXXXX.xxx see xxx.xxxxxx.xxx or call 0-000-000-0000 or (000) 000-0000 for a list of participating providers0000. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 26 for how this plan pays different kinds of providers. HealthMate Coast-to-Coast Coverage Period: 07/01/2016 - 06/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: See below Plan Type: PPO Do I need a referral to see a specialist? No. You don't need referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 830. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 2030% would be $200300. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In Network in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your cost if you use Cost If You Use an In Network In-network Provider Your cost if you use Cost If You Use an Out-of-Network network Provider Limitations & Exceptions Common Medical Event Services You May Need Your Cost If you visit a health care provider’s office or clinic You Use an In-network Provider Your Cost If You Use an Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $10 25 copay per visit $10 copay plus 20% coinsurance coinsurance, after deductible per visit ––––––––––––none–––––––––––– Specialist visit $10 35 copay per visit $10 copay plus 20% coinsurance coinsurance, after deductible per visit ––––––––––––none–––––––––––– If you visit a health care provider’s office or clinic Other practitioner office visit $10 35 copay per visit $10 copay plus 20% coinsurance coinsurance, after deductible per visit Chiropractic Services are Coverage limited to 12 50 visit maximum for Chiropractic care combined with physical, occupational, and speech therapy, per member per calendar year. Excess coverage beyond 50 visits per year; $15 copay for allergy subject to out of network deductible and dermatology office visits coinsurance. Preventive care/screening/immunization No Charge $10 copay plus 20% coinsurance after deductible Member liability for Out-of-Network is based on services received; 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 after deductible Preauthorization is recommended for certain services Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance after deductible Preauthorization is recommended If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.XXXXXX.xxx. Tier 1 generally low cost generic drugs $5 copay per prescription (retail) $15 copay per prescription (mail- order) Not covered No Charge for certain preventive drugs Tier 2 generally high cost generic and preferred brand name drugs $20 copay per prescription (retail) $60 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 3 non- preferred brand name drugs $30 copay per prescription (retail) $90 copay per prescription (mail- order) Not covered Preauthorization is required for certain drugs Tier 4 specialty prescription drugs $30 copay per prescription (specialty pharmacy only) 50% coinsurance Infertility drugs: 20% coinsurance; Preauthorization is required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge 20% coinsurance after deductible Preauthorization is recommended Physician/surgeon fees No Charge 20% coinsurance after deductible ––––––––––––none–––––––––––– Diagnostic test (x-ray, blood work) No Charge 20% coinsurance, after deductible $25 Copay in hospital setting. If you have a test 20% coinsurance, after deductible $375 Copay maximum per member per calendar year. Prior authorization is required. Imaging (CT/PET scans, MRIs) $75 Copay If you need immediate medical attention Emergency room services drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxxxxx.xxx. Generic drugs $5 copay/ retail and $7.50 copay/mail order Preferred brand drugs $25 copay/ retail and $37.50 copay/mail order 20% coinsurance, after deductible Retal: 30 day maximum supply Mail order: 90 day maximum supply Non-preferred brand drugs $40 copay/ retail and $60 copay/mail order Common Medical Event Services You May Need Your Cost If You Use an In-network Provider Your Cost If You Use an Out-of-network Provider Limitations & Exceptions Specialty drugs $40 copay/ retail and $60 copay/mail order If you have outpatient surgery Facility fee – General Hospital $100 copay per visit $100 copay per visit Copay waived if admitted Emergency medical transportation $50 copay per trip $50 copay per trip 20% coinsurance, after deductible ––––––––––––none–––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions Urgent care $10 copay per urgent care center visit $10 copay plus 20% coinsurance after deductible per urgent care center visit Applies to the visit only. If additional services are provided additional out of pockets costs would apply based on services received. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fees No Charge 20% coinsurance coinsurance, after deductible 45 day limit at an inpatient rehabilitation facility; Preauthorization is recommended Physician/surgeon fee No Charge 20% coinsurance after deductible ––––––––––––none–––––––––––– Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient need immediate medical attention Emergency room services $10 150 copay $150 copay/office visit Copay waived if admitted Emergency medical transportation No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Mental/Behavioral health inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Substance use disorder outpatient services $10 copay/office visit No Charge for outpatient services $10 copay plus 20% coinsurance after deductible/office visit 20% coinsurance after deductible for outpatient services Preauthorization is recommended for certain services Substance use disorder inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended If you are pregnant Prenatal and postnatal care No Charge 20% coinsurance after deductible ––––––––––––none–––––––––––– Delivery and all inpatient services No Charge 20% coinsurance after deductible Preauthorization is recommended Common Medical Event Services You May Need Your cost if you use an In Network Provider Your cost if you use an Out-of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health Urgent care No Charge 20% coinsurance after deductible $50 copay Not Covered ––––––––––––none–––––––––––– Rehabilitation If you have a hospital stay Facility fee (e.g., hospital room) $300 Copay per admission 20% coinsurance, after deductible Inpatient hospitalizations require authorizations. Physician/surgeon fee No Charge 20% coinsurance, after deductible ––––––––––––none–––––––––––– Mental/Behavioral health outpatient services $25 Copay 20% coinsurance, after deductible Prior authorization required. If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health inpatient services $300 Copay per admission 20% coinsurance, after deductible Prior authorization is required. Substance Abuse outpatient services $25 Copay 20% coinsurance, after deductible Prior authorization required. Substance Abuse inpatient services $300 Copay per admission 20% coinsurance, after deductible Prior authorization is required. Prenatal and postnatal care $35 Copay 20% coinsurance, after deductible Initial visit only is subject to in network $35 copay. No charge, thereafter. If you are pregnant Delivery and all inpatient services $300 Copay per admission 20% coinsurance, after deductible Prior authorization is required. Common Medical Event Services You May Need Your Cost If You Use an In-network Provider Your Cost If You Use an Out-of-network Provider Limitations & Exceptions Home health care No Charge $50 deductible applies and 20% coinsurance Home Health care services is limited to 200 visits per member per calendar year. Rehabilitation services $35 copay 20% coinsurance coinsurance, after deductible Includes Physical, Prior authorization required after the first visit for Physical Therapy and Occupational and Speech Therapy. Speech Therapy preauthorization is recommended Coverage limited to 50 visit limit for all visitsphysical, occupational, and speech therapy combined with Chiropractic care. Habilitative Excess coverage beyond 50 visits subject to out of network deductible and coinsurance. If you need help recovering or have other special health needs Habilitation services $35 Copay 20% coinsurance 20% coinsurance coinsurance, after deductible Includes Physical, Occupational All rehabilitation and Speech Therapy. Speech Therapy preauthorization is recommended for all visitshabilitation visits count toward your rehabilitation visit limit. Skilled nursing care No Charge $300 Copay per admission 20% coinsurance coinsurance, after deductible Preauthorization Prior authorization is recommended; Custodial Care is not covered required. Skilled nursing facility services limited to 120 days per member per calendar year. Durable medical equipment No charge 20% coinsurance 20% coinsurance coinsurance, after deductible Preauthorization is recommended for certain servicesFor a complete list of exclusions and limitations, please reference your Certificate of Coverage. Hospice service No Charge 20% coinsurance coinsurance, after deductible Preauthorization Prior authorization is recommended required. If your child needs dental or eye care Eye exam $10 copay $10 copay plus (routine or medical) No Charge 20% coinsurance coinsurance, after deductible Limited to one routine eye 1 exam per every calendar year. Glasses Not Covered Not Covered ––––––––––––none–––––––––––– Dental check-up Not Covered Not Covered ––––––––––––none–––––––––––– Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) • Acupuncture • Cosmetic surgery • surgery• Dental care (Adult) • Dental check-up, child • Glasses, child • Adult)• Weight loss programs• Long-term care • care• Routine foot care unless to treat a systemic condition • Weight loss programs Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • Bariatric Surgery • Chiropractic care (limits apply)• Hearing aids- (restrictions apply) • Hearing aids Non-emergency care when traveling outside the U.S. • Infertility treatment • Most coverage Coverage provided outside the United States. Contact Customer Service for more information. See xxx.XXXX.xxx/xxxxxxxxxxxxxxxxx • Bariatric surgery • Infertility treatment (restrictions apply) • Private-duty nursing nursing- (restrictions apply) • Routine eye care (Adult)care