Common use of NON-PMD PROVIDER/OUT OF NETWORK Clause in Contracts

NON-PMD PROVIDER/OUT OF NETWORK. For employees who do not choose to use a PMD provider, or who are outside the Alabama network and are unable to utilize the Preferred Care features, the following will apply. IN HOSPITAL DEDUCTIBLE (All hospital admissions, with the exception of emergencies, require pre-admission review prior to date of admission) $100 per confinement DAILY HOSPITAL Daily Room Limit Daily Daily Intensive Care Semi-private room charge – 120 days Two times the semi-private room charge – 120 days OTHER HOSPITAL CHARGES Unlimited – 120 days SURGEONS FEES $1,500 Maximum according to schedule (20% extra for assistant) Increased by 20 % for procedures performed on an out-patient basis. ADDITIONAL ACCIDENT $300 MATERNITY – HOSPITAL Same as above MATERNITY – DOCTOR Normal Cesarean Miscarriage $350 $500 $150 MAJOR MEDICAL Lifetime Maximum Deductible Co-Insurance – first $3,000 Co-Insurance thereafter Unlimited Individual - $200 Family - $600 80% - 20% 100% - 0% Daily Intensive Care Unit Limit Intensive Care Unit Room Charge Preferred Medical Doctor Co-pay - $25 Medical Case Management Program For various catastrophic illnesses requiring complex treatment and extended care

NON-PMD PROVIDER/OUT OF NETWORK. ‌ For employees who do not choose to use a PMD provider, or who are outside the Alabama network and are unable to utilize the Preferred Care features, the following will apply. IN HOSPITAL DEDUCTIBLE (All hospital admissions, with the exception of emergencies, require pre-admission review prior to date of admission) $100 per confinement DAILY HOSPITAL Daily Room Limit Daily Daily Intensive Care Semi-private room charge – 120 days Two times the semi-private room charge – 120 days OTHER HOSPITAL CHARGES Unlimited – 120 days SURGEONS FEES $1,500 Maximum according to schedule (20% extra for assistant) Increased by 20 % for procedures performed on an out-patient basis. ADDITIONAL ACCIDENT $300 MATERNITY – HOSPITAL Same as above MATERNITY – DOCTOR Normal Cesarean Miscarriage $350 $500 $150 MAJOR MEDICAL Lifetime Maximum Deductible Co-Insurance – first $3,000 Co-Insurance thereafter Unlimited Individual - $200 Family - $600 80% - 20% 100% - 0% Daily Intensive Care Unit Limit Intensive Care Unit Room Charge Preferred Medical Doctor Co-pay - $25 20 Medical Case Management Program For various catastrophic illnesses requiring complex treatment and extended care

NON-PMD PROVIDER/OUT OF NETWORK. For employees who do not choose to use a PMD provider, or who are outside the Alabama network and are unable to utilize the Preferred Care features, the following will apply. : IN HOSPITAL DEDUCTIBLE (All hospital admissions, with the exception of emergencies, require pre-admission review prior to date of admission) $100 per confinement DAILY HOSPITAL Daily Room Limit Daily Daily Intensive Care Semi-private room charge – 120 days Two times the semi-private room charge – 120 days OTHER HOSPITAL CHARGES Unlimited – 120 days SURGEONS FEES $1,500 Maximum according to schedule (20% extra for assistant) Increased by 20 % for procedures performed on an out-patient basis. ADDITIONAL ACCIDENT $300 MATERNITY – HOSPITAL Same as above MATERNITY – DOCTOR Normal Cesarean Miscarriage $350 $500 $150 MAJOR MEDICAL Lifetime Maximum Deductible Co-Insurance – first $3,000 Co-Insurance thereafter Unlimited $1,000,000 Individual - $200 Family - $600 80% - 20% 100% - 0% Daily Intensive Care Unit Limit Intensive Care Unit Room Charge Preferred Medical Doctor Co-pay - $25 20 Medical Case Management Program For various catastrophic illnesses requiring complex treatment and extended care