Common use of Medical Schedule of Benefits Clause in Contracts

Medical Schedule of Benefits. A detailed listing of benefits can be found in the health plan comparison chart distributed during annual open enrollment. No benefit available through December 31, 2019 shall be discontinued because it is excluded from the table which follows: Preferred Provider Network Summary of Benefits Commencing January 1, 2020 Employee Annual Deductible None None Co-insurance 100% of allowed benefit (no service restrictions) 80% of allowed benefit (no service restrictions) Employee Annual Out-of-Pocket Maximum $400 $2000/individual $4000/family Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 100% $100 deductible, 80% up to $1500 out-of- pocket/admission Outpatient Hospital (facility and doctor charges) 100% 80% allowed benefit Emergency Care in a Hospital $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with $10 copay for urgent care $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with no copay for urgent care visits $10 copay for urgent care Preferred Provider Network Continued. Point of Service Surgical Expenses 100% 80% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 80% of allowed benefit (no copay) Preventive Care Routine physical + related services Gyn exam Mammogram All services 100% at one per year 100% allowed benefit (no copay) 80% at one per year 80% allowed benefit (no copay) Well-Child Care 100% allowed benefit 80% allowed benefit Hospice 100% allowed benefit 100% allowed benefit Inpatient Mental Health Pays same as medical Pays same as medical Inpatient Substance Abuse Pays same as medical Pays same as medical Outpatient Mental Health Pays same as medical Pays same as medical Outpatient Substance Abuse Pays same as medical Pays same as medical Employee Annual Deductible $0.00 $0.00 Co-insurance 90% 70% Employee Annual Out-of-Pocket Maximum $1000/individual $2000/family None Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 90% 70% of allowed benefit, pre-auth required Outpatient Hospital (facility and doctor charges 90% 70% allowed benefit Emergency Care in a Hospital Urgent Care $100.00 copay by employee; waived if admitted to hospital $10 copay $100.00 copay by employee; waived if admitted to hospital $10 copay Surgical Expenses 90% 90% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 70% of allowed benefit Point of Service Continued. Health Maintenance Organization Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one per year 100% at one per year Covered in full $5 copay per visit, 70% of 50% allowed benefit $10 copay per visit, 70% of allowed benefit $10 copay per visit, 70% of allowed benefit Well-Child Care Covered in full $5 copay per visit, 70% of allowed benefit Hospice 90% Outpatient: pre-auth required 70% of allowed benefit Outpatient: pre-auth required Inpatient Mental Health 90% pre-auth required 70% of allowed benefit, pre-auth required Inpatient Substance Abuse 90% pre-auth required 70% of allowed benefit, pre-auth required Outpatient Mental Health $10 copay per office visit, covered in full all other services 70% of allowed benefit Outpatient Substance Abuse $10 copay per office visit, covered in full all other services 70% of allowed benefit Employee Annual Deductible N/A Co-insurance 100% Employee Annual Out-of-Pocket Maximum (excludes mental health Individual: $1,100 Family: $3,600 Includes mental and nervous coverage. The following services do not apply to out-of-pocket maximum: Outpatient drugs, supplies, and supplements, including blood, blood products, and medical foods Inpatient and outpatient infertility services Lifetime Maximum Benefit Unlimited Inpatient Hospital (facility and doctor charges) 100% Outpatient Hospital (facility and doctor charges 100% Emergency Care in a Hospital Urgent Care $100 copay (waived if admitted) [$100] $10 copay per visit Surgical Expenses 100% Doctor’s Office Visits $5.00 copay for primary physician, $10.00 copay for specialists Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one/yr. 100% at one/yr. 100% per schedule of freq. Health Maintenance Organization Continued. Well-Child Care 100% Hospice 100% Inpatient Mental Health 100% Inpatient Substance Abuse 100% Outpatient Mental Health $5 copay per visit Outpatient Substance Abuse $5 copay per visit

Medical Schedule of Benefits. A detailed listing of benefits can be found in the health plan comparison chart distributed during annual open enrollment. No benefit available through December 31, 2019 shall be discontinued because it is excluded from the table which follows: Preferred Provider Plan Feature In-Network Summary of Benefits Commencing January 1, 2020 Employee Annual Deductible None None Co-insurance 100% of allowed benefit (no service restrictions) 80% of allowed benefit (no service restrictions) Employee Annual Out-of-Pocket Maximum $400 $2000/individual $4000/family Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 100% $100 deductible, 80% up to $1500 out-of- pocket/admission Outpatient Hospital (facility and doctor charges) 100% 80% allowed benefit Emergency Care in a Hospital $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with $10 copay for urgent care $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with no copay for urgent care visits $10 copay for urgent care Preferred Provider Network Continued. Point of Service Surgical Expenses 100% 80% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 80% of allowed benefit (no copay) Preventive Care Routine physical + related services Gyn exam Mammogram All services 100% at one per year 100% allowed benefit (no copay) 80% at one per year 80% allowed benefit (no copay) Well-Child Care 100% allowed benefit 80% allowed benefit Hospice 100% allowed benefit 100% allowed benefit Inpatient Mental Health Pays same as medical Pays same as medical Inpatient Substance Abuse Pays same as medical Pays same as medical Outpatient Mental Health Pays same as medical Pays same as medical Outpatient Substance Abuse Pays same as medical Pays same as medical Employee Annual Deductible $0.00 $0.00 Co-insurance 90% 70% Employee Annual Out-of-Pocket Maximum $1000/individual $2000/family None Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 90% 70% of allowed benefit, pre-auth required Outpatient Hospital (facility and doctor charges charges) 90% 70% of allowed benefit Emergency Care in a Hospital Urgent Care $100.00 copay by employee; waived if admitted to hospital $10 copay $100.00 copay by employee; waived if admitted to hospital Urgent Care $10 copay $10 copay Surgical Expenses 90% 9070% Doctor’s Office Visits $10.00 copay for Doctor’s Office primary physician, 70% of allowed Visits $20.00 copay for benefit specialists 70% of allowed benefit Point of Service Continued. Health Maintenance Organization Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one per year 100% at one per year Covered in full $5 copay per visit, 70% of 50% allowed benefit Gyn exam 100% at one per year $10 copay per visit, 70% of allowed benefit Mammogram Covered in full $10 copay per visit, 70% of allowed benefit Well-Child Care Covered in full $5 copay per visit, 70% of allowed benefit Hospice 90% Outpatient: pre-auth required 70% of allowed benefit Outpatient: pre-auth required Inpatient Mental Health 90% pre-auth required Inpatient Mental Health 70% of allowed benefit, pre-auth required Inpatient Substance Abuse 90% pre-auth required 70% of allowed benefit, pre-auth required Outpatient Mental Health $10 copay per office visit, covered in full all other services 70% of allowed benefit Outpatient Substance Abuse $10 copay per office visit, covered in full all other services 70% of allowed benefit Plan Feature In-Network Employee Annual Deductible N/A Co-insurance 100% Employee Annual Out-of-of- Pocket Maximum (excludes mental health Individual: health) $1,100 Family: 1,100/individual $3,600 3,600/family Includes mental and nervous coverage. The following services do not apply to out-out- of-pocket maximum: Outpatient drugs, supplies, and supplements, including includ- ing blood, blood products, and medical foods Inpatient and outpatient infertility infer- tility services Lifetime Maximum Benefit Unlimited Inpatient Hospital (facility and doctor charges) 100% Outpatient Hospital (facility and doctor charges charges) 100% Emergency Care in a Hospital Urgent Care $100 copay (waived if admitted) [$100] $10 copay per visit Surgical Expenses 100% Doctor’s Office Visits $5.00 copay for primary physician, $10.00 copay for specialists Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one/yr. one per year 100% at one/yr. one per year 100% per schedule of freq. Health Maintenance Organization Continued. Well-Child Care 100% Hospice 100% Inpatient Mental Health 100% Inpatient Substance Abuse 100% Outpatient Mental Health $5 copay per visit 100% Outpatient Substance Abuse $5 copay per visit100%

Medical Schedule of Benefits. A detailed listing of benefits can be found in the health plan comparison chart distributed during annual open enrollment. No benefit available through December 31, 2019 shall be discontinued because it is excluded from the table which follows: Preferred Provider Plan Feature In-Network Summary of Benefits Commencing January 1, 2020 Out-of-Network Employee Annual Deductible None None Co-insurance 100% of allowed benefit (no service restrictions) 80% of allowed benefit (no service restrictions) Employee Annual Out-of-Pocket Maximum $400 $2000/individual $4000/family Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 100% $100 deductible, 80% up to $1500 out-of- pocket/pocket/ admission Outpatient Hospital (facility and doctor charges) 100% 80% of allowed benefit Emergency Care in a Hospital $50.00 50 copay by employee; waived if admitted to hospital; Commencing Com- mencing January 1, 2019, $100 copay with $10 copay for urgent care $50.00 50 copay by employee; waived if admitted to hospitalhos- pital; Commencing January 1, 2019, $100 copay with no copay for urgent care visits $10 copay co- pay for urgent care Preferred Provider Network Continued. Point of Service Surgical Expenses 10010% 80% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 80% of allowed benefit (no copay) Preventive Care • Routine physical + related services • Gyn exam • Mammogram All services Services 100% at one per year 100% allowed benefit (no copay) 80% at one per year 80% allowed benefit (no copay) Well-Child Care 100% allowed benefit 80% allowed benefit Hospice 100% allowed benefit 100% allowed benefit Inpatient Mental Health Pays same as medical Pays same as medical Inpatient Substance Abuse Pays same as medical Pays same as medical Outpatient Mental Health Pays same as medical Pays same as medical Outpatient Substance Abuse Pays same as medical Pays same as medical Plan Feature In-Network Out-of-Network Employee Annual Deductible $0.00 $0.00 Co-insurance 90% 70% Employee Annual Out-of-Pocket Maximum $1000/individual $2000/family None Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 90% 70% of allowed benefit, pre-auth required Outpatient Hospital (facility and doctor charges charges) 90% 70% of allowed benefit Emergency Care in a Hospital Urgent Care $100.00 copay by employee; waived if admitted to hospital $10 copay $100.00 copay by employee; waived if admitted to hospital $10 copay Surgical Expenses 90% 9070% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 70% of allowed benefit Point of Service Continued. Health Maintenance Organization Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one per year 100% at one per year Covered in full $5 copay per visit, 70% of 50% allowed benefit $10 copay per visit, 70% of allowed benefit $10 copay per visit, 70% of allowed benefit Well-Child Care Covered in full $5 copay per visit, 70% of allowed benefit Hospice 90% Outpatient: pre-auth required 70% of allowed benefit Outpatient: pre-auth required Inpatient Mental Health 90% pre-auth required 70% of allowed benefit, pre-auth required Inpatient Substance Abuse 90% pre-auth required 70% of allowed benefit, pre-auth required Outpatient Mental Health $10 copay per office visit, covered in full all other services 70% of allowed benefit Outpatient Substance Abuse $10 copay per office visit, covered in full all other services 70% of allowed benefit Plan Feature In-Network Employee Annual Deductible N/A Co-insurance 100% Employee Annual Out-of-of- Pocket Maximum (excludes mental health Individual: health) $1,100 Family: 1,100/individual $3,600 3,600/family Includes mental and nervous coverage. The following services do not apply to out-out- of-pocket maximum: Outpatient drugs, supplies, and supplements, including includ- ing blood, blood products, and medical foods Inpatient and outpatient infertility infer- tility services Lifetime Maximum Benefit Unlimited Inpatient Hospital (facility and doctor charges) 100% Outpatient Hospital (facility and doctor charges charges) 100% Emergency Care in a Hospital Urgent Care $100 copay (waived if admitted) [$100] $10 copay per visit Surgical Expenses 100% Doctor’s Office Visits $5.00 copay for primary physician, $10.00 copay for specialists Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one/yr. one per year 100% at one/yr. one per year 100% per schedule of freq. Health Maintenance Organization Continued. Well-Child Care 100% Hospice 100% Inpatient Mental Health 100% Inpatient Substance Abuse 100% Outpatient Mental Health $5 copay per visit Outpatient Substance Abuse $5 copay per visit

Medical Schedule of Benefits. A detailed listing of benefits can be found in the health plan comparison chart distributed during annual open enrollment. No benefit available through December 31, 2019 2017 shall be discontinued because it is excluded from the table which follows: Preferred Provider Plan Feature In-Network Summary of Benefits Commencing January 1, 2020 Employee Annual Deductible None None Co-insurance 100% of allowed benefit (no service restrictions) 80% of allowed benefit (no service restrictions) Employee Annual Out-of-Pocket Maximum $400 $2000/individual $4000/family Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 100% $100 deductible, 80% up to $1500 out-of- pocket/admission Outpatient Hospital (facility and doctor charges) 100% 80% allowed benefit Emergency Care in a Hospital $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with $10 copay for urgent care $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with no copay for urgent care visits $10 copay for urgent care Preferred Provider Network Continued. Point of Service Surgical Expenses 100% 80% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 80% of allowed benefit (no copay) Preventive Care Routine physical + related services Gyn exam Mammogram All services 100% at one per year 100% allowed benefit (no copay) 80% at one per year 80% allowed benefit (no copay) Well-Child Care 100% allowed benefit 80% allowed benefit Hospice 100% allowed benefit 100% allowed benefit Inpatient Mental Health Pays same as medical Pays same as medical Inpatient Substance Abuse Pays same as medical Pays same as medical Outpatient Mental Health Pays same as medical Pays same as medical Outpatient Substance Abuse Pays same as medical Pays same as medical Employee Annual Deductible $0.00 $0.00 Co-insurance 90% 70% Employee Annual Out-of-Pocket Maximum $1000/individual $2000/family None Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 90% 70% of allowed benefit, pre-auth required Outpatient Hospital (facility and doctor charges 90% 70% allowed benefit Emergency Care in a Hospital Urgent Care $100.00 copay by employee; waived if admitted to hospital $10 copay $100.00 copay by employee; waived if admitted to hospital $10 copay Surgical Expenses 90% 90% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 70% of allowed benefit Point of Service Continued. Health Maintenance Organization Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one per year 100% at one per year Covered in full $5 copay per visit, 70% of 50% allowed benefit $10 copay per visit, 70% of allowed benefit $10 copay per visit, 70% of allowed benefit Well-Child Care Covered in full $5 copay per visit, 70% of allowed benefit Hospice 90% Outpatient: pre-auth required 70% of allowed benefit Outpatient: pre-auth required Inpatient Mental Health 90% pre-auth required 70% of allowed benefit, pre-auth required Inpatient Substance Abuse 90% pre-auth required 70% of allowed benefit, pre-auth required Outpatient Mental Health $10 copay per office visit, covered in full all other services 70% of allowed benefit Outpatient Substance Abuse $10 copay per office visit, covered in full all other services 70% of allowed benefit Employee Annual Deductible N/A Co-insurance 100% Employee Annual Out-of-Pocket Maximum Maxi- mum (excludes mental health health) Individual: $1,100 Family: $3,600 Includes mental and nervous coverage. The following services do not apply to out-of-of- pocket maximum: • Outpatient drugs, supplies, and supplements, including blood, blood products, and medical foods Inpatient and outpatient infertility services Lifetime Maximum Benefit Unlimited Inpatient Hospital (facility and doctor charges) 100% Outpatient Hospital (facility and doctor charges 100% Emergency Care in a Hospital Urgent Care $100 copay co-pay (waived if admitted) [$100] $10 copay 10.00 co-pay per visit Surgical Expenses 100% Doctor’s Office Visits $5.00 copay co-pay for primary physician, $10.00 copay co-pay for specialists Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one/yr. 100% at one/yr. 100% per schedule of freq. Health Maintenance Organization Continued. Well-Child Care 100% Hospice 100% Inpatient Mental Health 100% Inpatient Substance Abuse 100% Outpatient Mental Health $5 copay per visit Outpatient Substance Abuse $5 copay per visit Health Maintenance Organization Summary of Benefits Plan Feature In-Network Out-of-Network Employee Annual Deductible $0.00 $0.00 Co-insurance 90% 70% Employee Annual Out-of- Pocket Maximum $1,000/individual $2,000/family none Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 90% 70% of allowed benefit, pre-auth required Outpatient Hospital (facili- ty and doctor charges) 90% 70% of allowed benefit Emergency Care in a Hospital Urgent Care $100.00 co-pay by employ- ee; waived if admitted to hospital $10 co-pay $100.00 co-pay by employ- ee; waived if admitted to hospital $10 co-pay Surgical Expenses 90% 70% Doctor’s Office Visits $10.00 co-pay for primary physician, $20.00 co-pay for specialists 70% of allowed benefit Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one per year 100% at one per year Covered in full $5 co-pay per visit, 70% of allowed benefit $10 co-pay per visit, 70% of allowed benefit $10 co-pay per visit, 70% of allowed benefit Well-Child Care Covered in full $5 co-pay per visit, 70% allowed benefit Hospice 90% Outpatient: pre-auth required 70% of allowed benefit Outpatient: pre-auth required Inpatient Mental Health 90%, pre-auth required 70% of allowed benefit, pre-auth required Inpatient Substance Abuse 90%, pre-auth required 70% of allowed benefit, pre-auth required Outpatient Mental Health $10 co-pay per office visit, covered in full all other services 70% of allowed benefit Outpatient Substance Abuse $10 co-pay per office visit, covered in full all other services 70% of allowed benefit

Medical Schedule of Benefits. A detailed listing of benefits can be found in the health plan comparison chart distributed during annual open enrollment. No benefit available through December 31, 2019 shall be discontinued because it is excluded from the table which follows: Preferred Provider Plan Feature In-Network Summary of Benefits Commencing January 1, 2020 Out-of-Network Employee Annual Deductible None None Co-insurance 100% of allowed benefit (no service restrictions) 80% of allowed benefit (no service restrictions) Employee Annual Out-of-of- Pocket Maximum $400 $2000/individual $4000/family Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 100% $100 deductible, 80% up to $1500 out-of- pocket/admission Outpatient Hospital (facility and doctor charges) charges 100% 80% allowed benefit Emergency Care in a Hospital $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with $10 copay for urgent care $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with no copay for urgent care visits $10 copay for urgent care Preferred Provider Network Continued. Point of Service Surgical Expenses 100% 80% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 80% of allowed benefit (no copay) Preventive Care Routine physical + related services Gyn exam Mammogram All services 100% at one per year 100% allowed benefit (no copay) 80% at one per year 80% allowed benefit (no copay) Well-Child Care 100% allowed benefit 80% allowed benefit Hospice 100% allowed benefit 100% allowed benefit Inpatient Mental Health Pays same as medical Pays same as medical Inpatient Substance Abuse Pays same as medical Pays same as medical Outpatient Mental Health Pays same as medical Pays same as medical Outpatient Substance Abuse Pays same as medical Pays same as medical Plan Feature In-Network Out-of-Network Employee Annual Deductible $0.00 $0.00 Co-insurance 90% 70% Employee Annual Out-of-of- Pocket Maximum $1000/individual $2000/family None Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 90% 70% of allowed benefit, pre-pre- auth required Outpatient Hospital (facility and doctor charges 90% 70% of allowed benefit Emergency Care in a Hospital Urgent Care $100.00 copay by employee; waived if admitted to hospital $10 copay $100.00 copay by employee; waived if admitted to hospital $10 copay Surgical Expenses 90% 9070% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 70% of allowed benefit Point of Service Continued. Health Maintenance Organization Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one per year 100% at one per year Covered in full $5 copay per visit, 70% of 50% allowed benefit $10 copay per visit, 70% of allowed benefit $10 copay per visit, 70% of allowed benefit Well-Child Care Covered in full $5 copay per visit, 70% of allowed benefit Hospice 90% Outpatient: pre-auth required 70% of allowed benefit Outpatient: pre-auth required Inpatient Mental Health 90% pre-auth required 70% of allowed benefit, pre-pre- auth required Inpatient Substance Abuse 90% pre-auth required 70% of allowed benefit, pre-pre- auth required Outpatient Mental Health $10 copay per office visit, covered in full all other services 70% of allowed benefit Outpatient Substance Abuse $10 copay per office visit, covered in full all other services 70% of allowed benefit Plan Feature In-Network Employee Annual Deductible N/A Co-insurance 100% Individual: $1,100 Employee Annual Out-of-Pocket Maximum (excludes mental health Individual: $1,100 health) Family: $3,600 Includes mental and nervous coverage. The following services do not apply to out-of-pocket maximum: • Outpatient drugs, supplies, and supplements, including blood, blood products, and medical foods Inpatient and outpatient infertility services Lifetime Maximum Benefit Unlimited Inpatient Hospital (facility and doctor charges) 100% Outpatient Hospital (facility and doctor charges 100% Emergency Care in a Hospital Urgent Care $100 copay (waived if admitted) [$100] $10 copay per visit Surgical Expenses 100% Doctor’s Office Visits $5.00 copay for primary physician, $10.00 copay for specialists Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one/yr. 100% at one/yr. 100% per schedule of freq. Health Maintenance Organization Continued. Well-Child Care 100% Hospice 100% Inpatient Mental Health 100% Inpatient Substance Abuse 100% %; Outpatient Mental Health $5 copay per visit Outpatient Substance Abuse $5 copay per visit

Medical Schedule of Benefits. A detailed listing of benefits can be found in the health plan comparison chart distributed during annual open enrollment. No benefit available through December 31, 2019 shall be discontinued because it is excluded from the table which follows: Preferred Provider Plan Feature In-Network Summary of Benefits Commencing January 1, 2020 Out-of-Network Employee Annual Deductible None None Co-insurance 100% of allowed benefit (no service restrictions) 80% of allowed benefit (no service restrictions) Employee Annual Out-of-of- Pocket Maximum $400 $2000/individual $4000/family Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 100% $100 deductible, 80% up to $1500 out-of- pocket/admission Outpatient Hospital (facility and doctor charges) charges 100% 80% allowed benefit Emergency Care in a Hospital $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with $10 copay for urgent care $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with no copay for urgent care visits $10 copay for urgent care Preferred Provider Network Continued. Point of Service Surgical Expenses 100% 80% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 80% of allowed benefit (no copay) Preventive Care Routine physical + related services Gyn exam Mammogram All services 100% at one per year 100% allowed benefit (no copay) 80% at one per year 80% allowed benefit (no copay) Well-Child Care 100% allowed benefit 80% allowed benefit Hospice 100% allowed benefit 100% allowed benefit Inpatient Mental Health Pays same as medical Pays same as medical Inpatient Substance Abuse Pays same as medical Pays same as medical Outpatient Mental Health Pays same as medical Pays same as medical Outpatient Substance Abuse Pays same as medical Pays same as medical Plan Feature In-Network Out-of-Network Employee Annual Deductible $0.00 $0.00 Co-insurance 90% 70% Employee Annual Out-of-of- Pocket Maximum $1000/individual $2000/family None Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 90% 70% of allowed benefit, pre-pre- auth required Outpatient Hospital (facility and doctor charges 90% 70% of allowed benefit Emergency Care in a Hospital Urgent Care $100.00 copay by employee; waived if admitted to hospital $10 copay $100.00 copay by employee; waived if admitted to hospital $10 copay Surgical Expenses 90% 9070% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 70% of allowed benefit Point of Service Continued. Health Maintenance Organization Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one per year 100% at one per year Covered in full $5 copay per visit, 70% of 50% allowed benefit $10 copay per visit, 70% of allowed benefit $10 copay per visit, 70% of allowed benefit Well-Child Care Covered in full $5 copay per visit, 70% of allowed benefit Hospice 90% Outpatient: pre-auth required 70% of allowed benefit Outpatient: pre-auth required Inpatient Mental Health 90% pre-auth required 70% of allowed benefit, pre-pre- auth required Inpatient Substance Abuse 90% pre-auth required 70% of allowed benefit, pre-pre- auth required Outpatient Mental Health $10 copay per office visit, covered in full all other services 70% of allowed benefit Outpatient Substance Abuse $10 copay per office visit, 70% of allowed benefit Outpatient Substance Abuse covered in full all other services 70% of allowed benefit Plan Feature In-Network Employee Annual Deductible N/A Co-insurance 100% Employee Annual Out-of-Pocket Maximum (excludes mental health health) Individual: $1,100 Family: $3,600 Includes mental and nervous coverage. The following services do not apply to out-of-pocket maximum: • Outpatient drugs, supplies, and supplements, including blood, blood products, and medical foods Inpatient and outpatient infertility services Lifetime Maximum Benefit Unlimited Inpatient Hospital (facility and doctor charges) 100% Outpatient Hospital (facility and doctor charges 100% Emergency Care in a Hospital Urgent Care $100 copay (waived if admitted) [$100] $10 copay per visit Surgical Expenses 100% Doctor’s Office Visits $5.00 copay for primary physician, $10.00 copay for specialists Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one/yr. 100% at one/yr. 100% per schedule of freq. Health Maintenance Organization Continued. Well-Child Care 100% Hospice 100% Inpatient Mental Health 100% Inpatient Substance Abuse 100% %; Outpatient Mental Health $5 copay per visit Outpatient Substance Abuse $5 copay per visit

Medical Schedule of Benefits. A detailed listing of benefits can be found in the health plan comparison chart distributed during annual open enrollment. No benefit available through December 31, 2019 2017 shall be discontinued because it is excluded from the table which follows: Preferred Provider Plan Feature In-Network Summary of Benefits Commencing January 1, 2020 Out-of-Network Employee Annual Deductible None None Co-insurance 100% of allowed benefit (no service restrictions) 80% of allowed benefit (no service restrictions) Employee Annual Out-of-of- Pocket Maximum $400 $2000/individual $4000/family Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 100% $100 deductible, 80% up to $1500 out-of- pocket/admission Outpatient Hospital (facility and doctor charges) charges 100% 80% allowed benefit Emergency Care in a Hospital $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with $10 copay for urgent care $50.00 copay by employee; waived if admitted to hospital; Commencing January 1, 2019, $100 copay with no copay for urgent care visits $10 copay for urgent care Preferred Provider Network Continued. Point of Service Surgical Expenses 100% 80% Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 80% of allowed benefit (no copay) Preventive Care Routine physical + related services Gyn exam Mammogram All services 100% at one per year 100% allowed benefit (no copay) 80% at one per year 80% allowed benefit (no copay) Well-Child Care 100% allowed benefit 80% allowed benefit Hospice 100% allowed benefit 100% allowed benefit Inpatient Mental Health Pays same as medical Pays same as medical Inpatient Substance Abuse Pays same as medical Pays same as medical Outpatient Mental Health Pays same as medical Pays same as medical Outpatient Substance Abuse Pays same as medical Pays same as medical Plan Feature In-Network Out-of-Network Employee Annual Deductible $0.00 $0.00 Co-insurance 90% 70% Employee Annual Out-of-of- Pocket Maximum $1000/individual $2000/family None Lifetime Maximum Benefit Unlimited Unlimited Inpatient Hospital (facility and doctor charges) 90% 70% of allowed benefit, pre-pre- auth required Outpatient Hospital (facility and doctor charges 90% 70% of allowed benefit Emergency Care in a Hospital Urgent Care $100.00 copay by employee; waived if admitted to hospital $10 copay $100.00 copay by employee; waived if admitted to hospital $10 copay Surgical Expenses 90% 9070% 70% of allowed benefit Doctor’s Office Visits $10.00 copay for primary physician, $20.00 copay for specialists 70% of allowed benefit Point of Service Continued. Health Maintenance Organization Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one per year 100% at one per year Covered in full $5 copay per visit, 70% of 50% allowed benefit $10 copay per visit, 70% of allowed benefit $10 copay per visit, 70% of allowed benefit Well-Child Care Covered in full $5 copay per visit, 70% of allowed benefit Hospice 90% Outpatient: pre-auth required 70% of allowed benefit Outpatient: pre-auth required Inpatient Mental Health 90% pre-auth required 70% of allowed benefit, pre-pre- auth required Inpatient Substance Abuse 90% pre-auth required 70% of allowed benefit, pre-pre- auth required Outpatient Mental Health $10 copay per office visit, covered in full all other services 70% of allowed benefit Outpatient Substance Abuse $10 copay per office visit, covered in full all other services 70% of allowed benefit Plan Feature In-Network Employee Annual Deductible N/A Co-insurance 100% Employee Annual Out-of-Pocket Individual: $1,100 Maximum (excludes mental health Individual: $1,100 health) Family: $3,600 Includes mental and nervous coverage. The following services do not apply to out-of-pocket maximum: • Outpatient drugs, supplies, and supplements, including blood, blood products, and medical foods Inpatient and outpatient infertility services Lifetime Maximum Benefit Unlimited Inpatient Hospital (facility and doctor charges) 100% Outpatient Hospital (facility and doctor charges 100% Emergency Care in a Hospital Urgent Care $100 copay (waived if admitted) [$100] $10 copay per visit Surgical Expenses 100% Doctor’s Office Visits $5.00 copay for primary physician, $10.00 copay for specialists Preventive Care Routine physical + related services Gyn exam Mammogram 100% at one/yr. 100% at one/yr. 100% per schedule of freq. Health Maintenance Organization Continued. Well-Child Care 100% Hospice 100% Inpatient Mental Health 100% Inpatient Substance Abuse 100% %; Outpatient Mental Health $5 copay per visit Outpatient Substance Abuse $5 copay per visit