Health Insurance Matrix 07/01/012-06/30/13

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1 Employee Contributions Family Monthly : $ Bi-Weekly : $ Monthly : $ Bi-Weekly : $ Monthly : $ Bi-Weekly : $ Monthly : $ Bi-Weekly : $ Employee Contributions Individual Monthly : $80.04 Bi-Weekly : $40.02 Monthly : $ Bi-Weekly : $73.28 Monthly : $ Bi-Weekly : $81.11 Monthly : $ Bi-Weekly : $ Office Visits Primary Care Physician: $25 Specialist: $25 Primary Care Physician: $20 Specialist: $20 Primary Care Physician: $20 Specialist: $20 In Network : $20 Preventive care - including routine physical, gynecological, well child, school, camp, sports, and premarital examinations Routine OB-GYN Exams Pap Smears Included as part of the physical exam Included as part of the physical exam Included as part of the physical exam In Network : $0 (one per calendar year) Included as part of the physical exam Routine Colonoscopy Chiropractic Services $25 co-payment $20 co-payment $20 co-payment In Network : $20 (20 visits) Diagnostic Laboratory and X-Rays High Tech Radiology - CT Scans, MRIs, and PET Scans Dependent Coverage $75 co-payment (No Deductible) $75 co-payment $75 co-payment In Network : $75 co-payment financial dependency, student status, marital or employment status. Page 1 of 5

2 Emergency Room Visits No deductible In Network : $100/visit (waived if admitted or for observation stay) Out-of-Network : $100/visit, no deductible observation stay) Mental Health Counseling $25 co-payment - Individual Therapy $20 co-payment - Individual Therapy $20 co-payment - Individual Therapy In Network : $10 co-payment - Group Therapy $20 co-payment - Individual Therapy Doctor Selection HMO Network HMO Network HMO Network In Network : Out-of-Network : All Others Pre-Existing Condition No restriction No restriction No restriction No restriction Out-of-Area Emergency Care Non-Emergency Hospital Admission Prescription Drugs Retail (Any participating pharmacy) Prescription Drugs Mail Order - 90-Day Supply Pediatric Preventive Dental Coverage for Dependent Children under 12 years - Two visits per member per calendar year, including examination, cleaning, x- rays and fluoride treatment Page 2 of 5

3 Calendar Year Deductibles For some services, you must meet a deductible before services are provided: $1,000 for each member, or $2,000 In Network : Out of Network : $250 for each member, or $500 for all family members covered under the same membership Calendar Year Out-of- Pocket Maximum: includes all medical copayments, deductible and coinsurance. Does not include prescription copayments $5,000 for each member, or $10,000 $2,000 for each member, or $4,000 In Network : Out of Network : $1,250 for each member, or $2,500 for all family members covered under the same membership Inpatient Hospital Services - Semi-Private Room Inpatient Hospital Services - Private Room Yes Yes Yes Yes When medically necessary When medically necessary When medically necessary When medically necessary Inpatient Hospital Care & Surgery after the deductible. $1,000 deductible for each member, or $2,000 for all family members covered under $500 co-payment per admission In Network : No cost Outpatient (Day) Surgery Hospital or Surgical Facility $250 co-pay per visit In Network: No cost Out-of-Network: 20% co-insurance Page 3 of 5

4 Outpatient (Day) Surgery Office Setting Applicable Office Visit Copay Applies Applicable Office Visit Copay Applies Applicable Office Visit Copay Applies In Network : Applicable Office Visit Copay Applies Lifetime Maximum (Catastrophic Illness) None None None None Optical Vision Exam - One per calendar year, 35-45% on frames and 10-15% on contact Vision Exam - One per calendar year, 35-45% on frames and 10-15% on contact Vision Exam - One per calendar year 35-45% on frames and 10-15% on contact Vision Exam - One per calendar year, 35-45% on frames and 10-15% on contact Durable Medical Equipment 20% cost share 20% cost share 20% cost Share 20% cost share Diabetic Equipment and visual magnifying aids - Covered in full (No Deductible) Insulin, insulin syringes, insulin pens with insulin, lancets, oral agents for controlling blood sugar, blood test strips, and glucose, ketone and urine test strips - Subject to the applicable Wellness Plans (CAM): 10%-30% s on (CAM): 10%-30% s on (CAM): 10%-30% s on Complementary Alternative Medicine (CAM): 10%-30% s on services such as massage therapy, acupuncture, stress reduction, and mind-body therapy Page 4 of 5

5 Unique Features Allergy Injections: Deductible applies Disorder Treatment: 100% after deductible - no limit (Physical and Occupational): 100% - Covered up to 30 visits each per calendar year Allergy Injections: $5 co-payment Disorder Treatment: $20 copayment - no limit (Physical and Occupational): $20 copayment - Covered up to 30 visits each per calendar year Allergy Injections: $5 co-payment On Line Tools: HPHConnect, Mind the moment, Healthwise, & well, then Allergy Injections: In-Network: $5 co-payment Disorder Treatment: Disorder Treatment: $20 copayment - In-Network: $20 copayment - no no limit (Physical and Occupational): $20 copayment - Covered up to 30 visits each per calendar year limit (Physical and Occupational): In-Network: $20 co-payment - Covered up to 30 visits each per calendar year Hospitals National network of providers and hospitals For a complete description of benefits, please refer to your plan certificate (booklet). In case of a discrepancy, the plan certificate will prevail. Page 5 of 5

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