Health Insurance Matrix 01/01/16-12/31/16

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1 Employee Contributions Family Monthly : $ Bi-Weekly : $60.60 Monthly : $ Bi-Weekly : $ Monthly : $ Bi-Weekly : $ Monthly : $ Bi-Weekly : $ Employee Contributions Individual Monthly : $45.73 Bi-Weekly : $22.86 Monthly : $ Bi-Weekly : $54.80 Monthly : $ Bi-Weekly : $81.42 Monthly : $ Bi-Weekly : $ Office Visits Preventive care - including routine physical, gynecological, well child, school, camp, sports, and premarital exams Routine OB-GYN Exams Primary Care Physician: $0 after Specialist: $0 Primary Care Physician: $25 Specialist: $25 Primary Care Physician: $25 Specialist: $25 In Network : $25 In Network : $0 (one per calendar year) Pap Smears Included as part of the physical exam Included as part of the physical exam Included as part of the physical exam Included as part of the physical exam Routine Colonoscopy Chiropractic Services $25 co-payment $25 co-payment In Network : $25 (20 visits) Diagnostic Laboratory and X-Rays High Tech Radiology - CT Scans, MRIs, and PET Scans $75 co-payment (No Deductible) Only charged twice annually $75 co-payment Only charged twice annually In Network : $75 co-payment Dependent Coverage Page 1 of 5

2 Emergency Room Visits No (waived if admitted or for observation) (waived if admitted or for observation) (waived if admitted or for observation stay) Mental Health Counseling $10 co-payment - Group Therapy $10 co-payment - Group Therapy In Network : $10 co-payment - Group 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 Dental Care, Routine Exams, Cleaning After After N/A N/A N/A N/A Page 2 of 5

3 Pediatric Preventive Dental Coverage for Dependent Children under age 13 Calendar Year Deductibles For most services, you must meet a before services are provided: $1,500 for an individual, or $3,000 for a family. If enrolled in a family contract the entire family must be satisfied before will begin to pay claims for any family member. For some services, you must meet a before services are provided: $1,000 for each member, or $2,000 for N/A In Network : N/A Out of Network : $500 for each member, or $1,000 for all family members covered under the same membership Calendar Year Out-of- Pocket Maximum: includes all medical copayments, and coinsurance. $5,000 for each member, or $10,000 for all family members covered under the 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. $1,000 for each member, or $2,000 for all family members covered under the $500 co-payment per admission In Network : $500 co-payment Page 3 of 5

4 Outpatient (Day) Surgery Hospital or Surgical Facility Outpatient (Day) Surgery Office Setting Lifetime Maximum (Catastrophic Illness) $250 co-pay per visit Applicable Office Visit Copay Applies Applicable Office Visit Copay Applies In Network: $250 co-payment Out-of-Network: 20% co-insurance In Network : Applicable Office Visit Copay Applies None None None None Optical 35-45% on frames and lenses 10-15% on contact lenses 35-45% on frames and lenses 10-15% on contact lenses 35-45% on frames and lenses 10-15% on contact lenses 35-45% on frames and lenses 10-15% on contact lenses Durable Medical Equipment 20% cost share 20% cost share 20% cost share In Network: 20% cost share Out of network: 20% cost share after Diabetic Equipment. magnifying aids - after. (No Deductible).. Page 4 of 5

5 Wellness Plans (CAM): 10%-30% s on services (CAM): 10%-30% s on services (CAM): 10%-30% s on services (CAM): 10%-30% s on services Unique Features Allergy Injections: Deductible applies Disorder Treatment: 100% after - no limit (Physical and Occupational): 100% - Covered up to 30 visits each per calendar year Allergy Injections: Deductible applies Disorder Treatment: 100% after - no limit (Physical and Occupational): 100% - Covered up to 30 visits each per calendar year Allergy Injections: $5 co-payment Disorder Treatment: $25 copayment - no limit (Physical and Occupational): $25 copayment - Covered up to 30 visits each per calendar year Allergy Injections: In-Network: $5 co-payment Disorder Treatment: In-Network: $25 copayment - no limit (Physical and Occupational): In-Network: $25 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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