Common use of Other Clarifications (All Employees and Retirees) Clause in Contracts

Other Clarifications (All Employees and Retirees). The following first four clarifications shall apply to all employees and retirees who are not cross-covered as set forth in paragraph 3 above. The fifth bullet applies to all employees and retirees including those who are cross- covered as set forth in paragraph 3 above. ! No co-pays apply to annual deductibles or the out of pocket maximums. ! The deductible will not apply to out of pocket maximum. ! The $100 emergency room co-pay shall be applied to each and every visit to the emergency room (waived only if admitted). ! The $5/$20 (Generic/Brand) prescription co-pays assumes the same $5/$20 co-pay for a 30 day maximum supply at retail, 90 day “Advantage 90”, or a 180 day (maintenance only) maximum at mail order, or “Advantage 90.” ! Prescription benefits include and are subject to manufacturer quantity limit restrictions in accordance with maximum quantities that may be dispensed in a single prescription. This applies to all participants including cross covered.

Other Clarifications (All Employees and Retirees). The following first four clarifications shall apply to all employees and retirees who are not cross-covered as set forth in paragraph 3 1 above. The fifth bullet applies to all employees and retirees including those who are cross- cross-covered as set forth in paragraph 3 1 above. ! • No co-pays apply to annual deductibles or the out of pocket maximums. ! • The deductible will not apply to out of pocket maximum. ! • The $100 emergency room co-pay shall be applied to each and every visit to the emergency room (waived only if admitted). ! • The $5/$20 (Generic/Brand) prescription co-pays pay assumes the same $5/$20 co-pay for a 30 day maximum supply at retail, 90 day “Advantage 90”, or a 180 day (maintenance only) maximum at mail order, or “Advantage 90.” ! • Prescription benefits include and are subject to manufacturer quantity limit restrictions in accordance with maximum quantities that may be dispensed in a single prescription. This applies to all participants including cross covered.

Other Clarifications (All Employees and Retirees). The following first four (4) clarifications shall apply to all employees and retirees who are not cross-cross covered as set forth in paragraph 3 10 above. The fifth bullet applies to all employees and retirees including those who are cross- cross covered as set forth in paragraph 3 6 above. !  No co-pays apply to annual deductibles or the out of pocket maximums. !  The deductible will not apply to out of pocket maximum. !  The $100 emergency room co-pay shall be applied to each and every visit to the emergency room (waived only if admitted). !  The $5/$20 10/$35 (Generic/Brand) prescription co-pays pay assumes the same $5/$20 10/$35 co-pay for a 30 30-90-day maximum supply at retail, 90 day “Advantage 90”, or retailer a 180 180-day (maintenance only) maximum at mail order, or “Advantage 90.” ! .  Prescription benefits include and are subject to manufacturer quantity limit restrictions in accordance with maximum quantities that may be dispensed in a single prescription.  This applies to all participants including cross covered.