Individual & Family Plan Options Unity Prime Network (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties)

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1 Unity Prime Network (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Platinum Plans These plans will cover about 90% of your service and you are responsible for the other 10% Benefits Unity Prime Platinum Unity Prime Platinum Unity Prime Platinum Unity Prime Platinum Unity Prime Platinum 10 / / / / / 30 Deductible (Single / Family) $0 / $0 $500 / $1,000 $0 / $0 $500 / $1,000 $0 / $0 0% 20% 30% 20% 0% Maximum Out-of-Pocket $1,400 / $2,800 $1,600 / $3,200 $1,900 / $3,800 $1,500 / $3,000 $2,000 / $4,000 e-visits $5 $10 $10 $10 $5 Office Visit Copay (PCP / Specialist) $10 / $50 $15 / $50 $20 / $70 $15 / $30 $10 / $30 Urgent Care Copay $50 $50 $70 $30 $30 Emergency Room Copay $60 $50 $70 $75 $100 Mental Health Outpatient Copay $10 $15 $20 $15 $10 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Deductible then Deductible then Pharmacy Copay $4 / $26 / $60 / $200 $4 / $26 / $60 / $200 $4 / $26 / $60 / $200 $10 / $25 / $50 / $200 $10 / $25 / $50 / $200 Dental Coverage Options for an Additional Charge? Child or Family Child or Family Child or Family None* or Family None* or Family HSA Eligible? No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. UH01445 (0715)

2 Unity Prime Network (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Gold Plans These plans will cover about 80% of your service and you are responsible for the other 20% Benefits Unity Prime Gold Unity Prime Gold Unity Prime Gold Unity Prime Gold Unity Prime Gold 15 / / 70 Deductible 30 / / 40 Deductible (Single / Family) $1,000 / $2,000 $1,500 / $3,000 $1,300 / $2,600 $1,000 / $2,000 $1,500 / $3,000 20% 20% 20% 20% 20% Maximum Out-of-Pocket $3,800 / $7,600 $5,200 / $10,400 $2,650 / $5,300 $4,500 / $9,000 $6,000 / $12,000 e-visits $10 $10 No Benefit $20 $10 Office Visit Copay (PCP / Specialist) $15 / $55 $20 / $70 Deductible then $30 / $60 $20 / $40 Urgent Care Copay $55 $70 Deductible then $60 $40 Emergency Room Copay $70 $100 Deductible then $100 $65 Mental Health Outpatient Copay $15 $20 Deductible then $30 $20 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Deductible then Deductible then Pharmacy Copay $4 / $26 / $60 / $200 $4 / $26 / $60 / $200 Deductible then $10 / $25 / $50 / $200 $10 / $25 / $50 / $200 Dental Coverage Available for an Additional Charge? Child or Family Child or Family None* or Child None* or Family None* or Family HSA Eligible? No No Yes** No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01445 (0715)

3 Unity Prime Network (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Silver Plans These plans will cover about 70% of your service and you are responsible for the other 30% Benefits Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver 25 / / / 110 Deductible Maintenance Maintenance 30 / / / / / / / 70 Deductible $2,300 / $4,600 $5,000 / $10,000 $4,300 / $8,600 $2,000 / $4,000 $925 / $1,850 $3,200 / $6,400 $2,750 / $5,500 $5,000 / $10,000 $4,300 / $8,600 $3,000 / $6,000 $4,000 / $8,000 (Single / Family) 45% 0% 30% 30% 0% 0% 30% 0% 30% 20% 50% Maximum $6,550 / $13,100 $6,500 / $13,000 $6,500 / $13,000 $4,900 / $9,800 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 Out-of-Pocket e-visits $15 $10 $20 No Benefit $10 $20 $20 $10 $30 $15 $20 Office Visit Copay $25 / $85 $20 / $65 $35 / $110 Deductible then $20 / $60 $30 / $70 $30 / $60 $20 / $60 $40 / $75 $25 / $50 $40 / $90 (PCP / Specialist) Urgent Care Copay $85 $65 $110 Deductible then $60 $70 $60 $60 $75 $50 $90 Emergency Room $200 $65 $300 Deductible then $500 $500 $260 $150 $300 $200 $300 Copay Mental Health $25 $20 $35 Deductible then $20 $30 $30 $20 $40 $25 $40 Outpatient Copay Hospital Copay Deductible then Deductible then Deductible then Deductible then $3,000 per diem / $3,000 per diem / Deductible then Deductible then Deductible then Deductible then Deductible then (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay $10 / $30 / $10 / $30 / $10 / $30 / Deductible then $5 / $60 / $5 / $60 / $10 / $30 / $10 / $30 / $10 / $30 / $10 / $50 / $10 / $50 / $70 / $200 $70 / $200 $70 / $200 $120 / $200 $120 / $200 / $70 / $200 / $70 / $200 / $70 / $200 / $100 / $200 $100 / $200 Dental Coverage Child or Family Child or Family Child or Family None* or Child None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family Available for an Additional Charge? HSA Eligible? No No No Yes** No No No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01445 (0715)

4 Unity Prime Network (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Bronze Plans These plans will cover about 60% of your service and you are responsible for the other 40% Benefits Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Bronze HSA Bronze 55 / 150 Bronze 40 / 100 Bronze Deductible Bronze 30 / Deductible Deductible (Single / Family) $5,400 / $10,800 $5,600 / $11,200 $6,550 / $13,100 $6,600 / $13,200 $6,600 / $13,200 50% 20% 0% 0% 0% Maximum Out-of-Pocket $6,400 / $12,800 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 e-visits No Benefit $25 $25 No Benefit $20 Office Visit Copay (PCP / Specialist) Deductible then $55 / $150 $40 / $100 Deductible then $30 / Deductible then Urgent Care Copay Deductible then $150 $100 Deductible then Deductible then Emergency Room Copay Deductible then $500 $300 Deductible then Deductible then Mental Health Outpatient Copay Deductible then $55 $40 Deductible then $30 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Deductible then Deductible then Pharmacy Copay Deductible then $20 / $60 / $120 / $200 Deductible then $10 / $50 / $100 / $200 Deductible then Dental Coverage Available for an Additional Charge? None* or Child None* or Family None* or Family None* or Family None* or Family HSA Eligible? Yes** No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01445 (0715)

5 Unity Prime Network (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Catastrophic Plans Only individuals under 30 years old or with a hardship exemption qualify for Catastrophic Plans Benefits Unity Prime Catastrophic Deductible (Single / Family) $6,600 / $13,200 0% Maximum Out-of-Pocket $6,600 / $13,200 e-visits Office Visit Copay (PCP / Specialist) Urgent Care Copay Emergency Room Copay Mental Health Outpatient Copay Hospital Copay (Inpatient / Outpatient) Pharmacy Copay Dental Coverage Available for an Additional Charge? HSA Eligible? No Benefit $0** / Deductible then Deductible then Deductible then Deductible then Deductible then Deductible then None* or Child No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. ** Only applies to the first three office visits with PCP then deductible then coinsurance applies. UH01445 (0715)

6 Unity Prime Network (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Optional Family Dental Adult Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 20% No Coverage $600 Benefit Maximum per Year dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage $600 Benefit Maximum per Year gingivectomy, dentures, implants and occlusal guards Orthodontics Not Covered Not Covered Not Covered Pediatric (up to age 19) Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 30% No Coverage No Benefit Maximum dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage No Benefit Maximum gingivectomy, dentures, implants and occlusal guards Orthodontics Covered only when medically necessary and a 24 month wait 50% coinsurance No Coverage No Benefit Maximum period is satisfied. UH01445 (0715)

7 Unity Prime Network (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Optional Child Dental Pediatric (up to age 19) Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 30% No Coverage No Benefit Maximum dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage No Benefit Maximum gingivectomy, dentures, implants and occlusal guards Orthodontics Covered only when medically necessary and a 24 month wait 50% coinsurance No Coverage No Benefit Maximum period is satisfied. * If you have an HSA plan, you must meet your deductible before coinsurance applies for this benefit. UH01445 (0715)

8 Unity Prime Network Cost Share Reduction Plans (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) % of Federal Poverty Level Benefits Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver 25 / / / 110 Deductible Maintenance Maintenance 30 / / / / / / / 70 Deductible $0 / $0 $100 / $200 $50 / $100 $200 / $400 $0 / $0 $0 / $0 $0 / $0 $300 / $600 $150 / $300 $50 / $100 $0 / $0 (Single / Family) 0% 0% 10% 20% 0% 0% 10% 0% 0% 10% 0% Maximum $700 / $1,400 $600 / $1,200 $650 / $1,300 $400 / $800 $600 / $1,200 $675 / $1,350 $1,250 / $2,500 $525 / $1,050 $525 / $1,050 $600 / $1,200 $700 / $1,400 Out-of-Pocket e-visits $2 $2 $5 No Benefit $2 $0 $3 $2 $3 $2 $2 Office Visit Copay $3 / $15 $3 / $20 $10 / $40 Deductible then $3 / $20 $0 / $10 $5 / $10 $3 / $10 $5 / $20 $3 / $15 $3 / $10 (PCP / Specialist) Urgent Care Copay $15 $20 $40 Deductible then $20 $10 $10 $10 $20 $15 $10 Emergency Room $15 $20 $40 Deductible then $75 $60 $100 $40 $100 $55 $40 Copay Mental Health $3 $3 $10 Deductible then $3 $0 $5 $3 $5 $3 $3 Outpatient Copay Hospital Copay Deductible then Deductible then Deductible then Deductible then $300 per diem / $250 per diem / Deductible then Deductible then Deductible then Deductible then Deductible then (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay $2 / $10 / $2 / $10 / $2 / $10 / Deductible then $2 / $25 / $0 / $20 / $2 / $10 / $2 / $10 / $2 / $10 / $4 / $26 / $2 / $10 / $26 / $100 $26 / $100 $26 / $100 $50 / $100 $50 / $100 $26 / $100 $26 / $100 $26 / $100 $60 / $200 $26 / $100 Dental Coverage Child or Family Child or Family Child or Family None* or Child None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family Available for an Additional Charge? HSA Eligible? No No No No No No No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. UH01446 (0715)

9 Unity Prime Network Cost Share Reduction Plans (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) % of Federal Poverty Level Benefits Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver 25 / / / 110 Deductible Maintenance Maintenance 30 / / / / / / / 70 Deductible $500 / $1,000 $800 / $1,600 $200 / $400 $500 / $1,000 $0 / $0 $0 / $0 $300 / $600 $1,000 / $2,000 $700 / $1,400 $250 / $500 $250 / $500 (Single / Family) 20% 0% 20% 20% 0% 0% 20% 0% 10% 20% 0% Maximum $1,750 / $3,500 $1,600 / $3,200 $1,700 / $3,400 $1,200 / $2,400 $1,800 / $3,600 $2,250 / $4,500 $2,250 / $4,500 $1,700 / $3,400 $1,500 / $3,000 $1,750 / $3,500 $2,000 / $4,000 Out-of-Pocket e-visits $5 $10 $15 No Benefit $5 $3 $5 $3 $10 $10 $5 Office Visit Copay $10 / $45 $15 / $40 $25 / $80 Deductible then $10 / $35 $5 / $25 $10 / $20 $5 / $15 $20 / $40 $15 / $30 $10 / $30 (PCP / Specialist) Urgent Care Copay $45 $40 $80 Deductible then $35 $25 $20 $15 $40 $30 $30 Emergency Room $60 $50 $100 Deductible then $250 $250 $100 $75 $150 $150 $60 Copay Mental Health $10 $15 $25 Deductible then $10 $5 $10 $5 $20 $15 $10 Outpatient Copay Hospital Copay Deductible then Deductible then Deductible then Deductible then $800 per diem / $1,500 per diem / Deductible then Deductible then Deductible then Deductible then Deductible then (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay $4 / $26 / $4 / $26 / $4 / $26 / Deductible then $5 / $50 / $2 / $30 / $4 / $26 / $4 / $26 / $4 / $26 / $10 / $30 / $4 / $26 / $60 / $200 $60 / $200 $60 / $200 $100 / $200 $60 / $100 $60 / $200 $60 / $200 $60 / $200 $70 / $200 $60 / $100 Dental Coverage Child or Family Child or Family Child or Family None* or Child None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family Available for an Additional Charge? HSA Eligible? No No No No No No No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. UH01446 (0715)

10 Unity Prime Network Cost Share Reduction Plans (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) % of Federal Poverty Level Benefits Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Unity Prime Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver 25 / / / 110 Deductible Maintenance Maintenance 30 / / / / / / / 70 Deductible $2,300 / $4,600 $4,700 / $9,400 $2,800 / $5,600 $1,500 / $3,000 $925 / $1,850 $750 / $1,500 $2,750 / $5,500 $4,000 / $8,000 $3,500 / $7,000 $2,600 / $5,200 $2,500 / $5,000 (Single / Family) 45% 0% 30% 30% 0% 0% 30% 0% 20% 20% 0% Maximum $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $3,250 / $6,500 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 Out-of-Pocket e-visits $15 $10 $20 No Benefit $10 $15 $20 $10 $25 $10 $10 Office Visit Copay $25 / $80 $20 / $65 $35 / $110 Deductible then $20 / $60 $25 / $65 $30 / $60 $20 / $55 $35 / $70 $20 / $40 $20 / $40 (PCP / Specialist) Urgent Care Copay $80 $65 $110 Deductible then $60 $65 $60 $55 $70 $40 $40 Emergency Room $200 $65 $300 Deductible then $500 $500 $260 $150 $300 $200 $200 Copay Mental Health $25 $20 $35 Deductible then $20 $25 $30 $20 $35 $20 $20 Outpatient Copay Hospital Copay Deductible then Deductible then Deductible then Deductible then $3,000 per diem / $3,000 per diem / Deductible then Deductible then Deductible then Deductible then Deductible then (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay $10 / $30 / $4 / $26 / $4 / $26 / Deductible then $5 / $60 / $5 / $60 / $10 / $30 / $10 / $30 / $4 / $26 / $10 / $50 / $10 / $50 / $70 / $200 $60 / $200 $60 / $200 $120 / $200 $120 / $200 $70 / $200 $70 / $200 $60 / $200 $100 / $100 $100 / $100 Dental Coverage Child or Family Child or Family Child or Family None* or Child None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family Available for an Additional Charge? HSA Eligible? No No No Yes** No No No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01446 (0715)

11 Unity Prime Network Cost Share Reduction Plans (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Optional Family Dental Adult Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 20% No Coverage $600 Benefit Maximum per Year dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage $600 Benefit Maximum per Year gingivectomy, dentures, implants and occlusal guards Orthodontics Not Covered Not Covered Not Covered Pediatric (up to age 19) Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 30% No Coverage No Benefit Maximum dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage No Benefit Maximum gingivectomy, dentures, implants and occlusal guards Orthodontics Covered only when medically necessary and a 24 month wait 50% coinsurance No Coverage No Benefit Maximum period is satisfied. UH01446 (0715)

12 Unity Prime Network Cost Share Reduction Plans (Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties) Optional Child Dental Pediatric (up to age 19) Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 30% No Coverage No Benefit Maximum dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage No Benefit Maximum gingivectomy, dentures, implants and occlusal guards Orthodontics Covered only when medically necessary and a 24 month wait 50% coinsurance No Coverage No Benefit Maximum period is satisfied. * If you have an HSA plan, you must meet your deductible before coinsurance applies for this benefit. UH01446 (0715)

13 Unity Elite Network (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) Platinum Plans These plans will cover about 90% of your service and you are responsible for the other 10% Benefits Unity Elite Platinum 15 / 30 Unity Elite Platinum 10 / 30 Deductible (Single / Family) $500 / $1,000 $0 / $0 20% 0% Maximum Out-of-Pocket $1,500 / $3,000 $2,000 / $4,000 e-visits $10 $5 Office Visit Copay (PCP / Specialist) $15 / $30 $10 / $30 Urgent Care Copay $30 $30 Emergency Room Copay $75 $100 Mental Health Outpatient Copay $15 $10 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay $10 / $25 / $50 / $200 $10 / $25 / $50 / $200 Dental Coverage Available for an Additional Charge? None* or Family None* or Family HSA Eligible? No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. UH01447 (0715)

14 Unity Elite Network (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) Gold Plans These plans will cover about 80% of your service and you are responsible for the other 20% Benefits Unity Elite Gold Deductible Unity Elite Gold 30 / 60 Unity Elite Gold 20 / 40 Deductible (Single / Family) $1,300 / $2,600 $1,000 / $2,000 $1,500 / $3,000 20% 20% 20% Maximum Out-of-Pocket $2,650 / $5,300 $4,500 / $9,000 $6,000 / $12,000 e-visits No Benefit $20 $10 Office Visit Copay (PCP / Specialist) Deductible then $30 / $60 $20 / $40 Urgent Care Copay Deductible then $60 $40 Emergency Room Copay Deductible then $100 $65 Mental Health Outpatient Copay Deductible then $30 $20 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Pharmacy Copay Deductible then $10 / $25 / $50 / $200 $10 / $25 / $50 / $200 Dental Coverage Available for an Additional Charge? None* None* or Family None* or Family HSA Eligible? Yes** No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01447 (0715)

15 Unity Elite Network (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) Silver Plans These plans will cover about 70% of your service and you are responsible for the other 30% Benefits Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Deductible Deductible Maintenance Maintenance 30 / / / / / / / 70 Deductible (Single / Family) $2,000 / $4,000 $925 / $1,850 $3,200 / $6,400 $2,750 / $5,500 $5,000 / $10,000 $4,300 / $8,600 $3,000 / $6,000 $4,000 / $8,000 30% 0% 0% 30% 0% 30% 20% 50% Maximum Out-of-Pocket $4,900 / $9,800 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 e-visits No Benefit $10 $20 $20 $10 $30 $15 $20 Office Visit Copay Deductible then $20 / $60 $30 / $70 $30 / $60 $20 / $60 $40 / $75 $25 / $50 $40 / $90 (PCP / Specialist) Urgent Care Copay Deductible then $60 $70 $60 $60 $75 $50 $90 Emergency Room Copay Deductible then $500 $500 $260 $150 $300 $200 $300 Mental Health Deductible then $20 $30 $30 $20 $40 $25 $40 Outpatient Copay Hospital Copay Deductible then $3,000 per diem / $3,000 per diem / Deductible then Deductible then Deductible then Deductible then Deductible then (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay Deductible then $5 / $60 / $5 / $60 / $10 / $30 / $10 / $30 / $10 / $30 / $10 / $50 / $10 / $50 $120 / $200 $120 / $200 $70 / $200 $70 / $200 $70 / $200 $100 / $200 $100 / $200 Dental Coverage Available None* None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family for an Additional Charge? HSA Eligible? Yes** No No No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01447 (0715)

16 Unity Elite Network (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) Bronze Plans These plans will cover about 60% of your service and you are responsible for the other 40% Benefits Unity Elite Unity Elite Unity Elite Unity Elite Unity Elite Bronze HSA Bronze 55 / 150 Bronze 40 / 100 Bronze Deductible Bronze 30 / Deductible Deductible (Single / Family) $5,400 / $10,800 $5,600 / $11,200 $6,550 / $13,100 $6,600 / $13,200 $6,600 / $13,200 50% 20% 0% 0% 0% Maximum Out-of-Pocket $6,400 / $12,800 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 e-visits No Benefit $25 $25 No Benefit $20 Office Visit Copay (PCP / Specialist) Deductible then $55 / $150 $40 / $100 Deductible then $30 / Deductible then Urgent Care Copay Deductible then $150 $100 Deductible then Deductible then Emergency Room Copay Deductible then $500 $300 Deductible then Deductible then Mental Health Outpatient Copay Deductible then $55 $40 Deductible then $30 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Deductible then Deductible then Pharmacy Copay Deductible then $20 / $60 / $120 / $200 Deductible then $10 / $50 / $100 / $200 Deductible then Dental Coverage Available for an None* None* or Family None* or Family None* or Family None* or Family Additional Charge? HSA Eligible? Yes** No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01447 (0715)

17 Unity Elite Network (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) Catastrophic Plans Only individuals under 30 years old or with a hardship exemption qualify for Catastrophic Plans Benefits Unity Elite Catastrophic Deductible (Single / Family) $6,600 / $13,200 0% Maximum Out-of-Pocket $6,600 / $13,200 e-visits Office Visit Copay (PCP / Specialist) Urgent Care Copay Emergency Room Copay Mental Health Outpatient Copay Hospital Copay (Inpatient / Outpatient) Pharmacy Copay Dental Coverage Available for an Additional Charge? HSA Eligible? No Benefit Deductible then Deductible then Deductible then Deductible then Deductible then Deductible then None* No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product UH01447 (0715)

18 Unity Elite Network (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) Optional Family Dental Adult Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 20% No Coverage $600 Benefit Maximum per Year dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage $600 Benefit Maximum per Year gingivectomy, dentures, implants and occlusal guards Orthodontics Not Covered Not Covered Not Covered Pediatric (up to age 19) Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 30% No Coverage No Benefit Maximum dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage No Benefit Maximum gingivectomy, dentures, implants and occlusal guards Orthodontics Covered only when medically necessary and a 24 month wait 50% coinsurance No Coverage No Benefit Maximum period is satisfied. Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product UH01447 (0715)

19 Unity Elite Network Cost Share Reduction Plans (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) % of Federal Poverty Level Benefits Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Deductible Maintenance Maintenance 30 / / / / / / / 70 Deductible (Single / Family) $200 / $400 $0 / $0 $0 / $0 $0 / $0 $300 / $600 $150 / $300 $50 / $100 $0 / $0 20% 0% 0% 10% 0% 0% 10% 0% Maximum Out-of-Pocket $400 / $800 $600 / $1,200 $675 / $1,350 $1,250 / $2,500 $525 / $1,050 $525 / $1,050 $600 / $1,200 $700 / $1,400 e-visits No Benefit $2 $0 $3 $2 $3 $2 $2 Office Visit Copay Deductible then $3 / $20 $0 / $10 $5 / $10 $3 / $10 $5 / $20 $3 / $15 $3 / $10 (PCP / Specialist) Urgent Care Copay Deductible then $20 $10 $10 $10 $20 $15 $10 Emergency Room Copay Deductible then $75 $60 $100 $40 $100 $55 $40 Mental Health Deductible then $3 $0 $5 $3 $5 $3 $3 Outpatient Copay Hospital Copay Deductible then $300 per diem / $250 per diem / Deductible then Deductible then Deductible then Deductible then Deductible then (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay Deductible then $2 / $25 / $50 / $100 $0 / $20 / $50 / $100 $2 / $10 / $26 / $100 $2 / $10 / $26 / $100 $2 / $10 / $26 / $100 $4 / $26 / $60 / $200 $2 / $10 / $26 / $100 Dental Coverage Available None* None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family for an Additional Charge? HSA Eligible? No No No No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product UH01448 (0715)

20 Unity Elite Network Cost Share Reduction Plans (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) % of Federal Poverty Level Benefits Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Deductible Maintenance Maintenance 30 / / / / / / / 70 Deductible (Single / Family) $500 / $1,000 $0 / $0 $0 / $0 $300 / $600 $1,000 / $2,000 $700 / $1,400 $250 / $500 $250 / $500 20% 0% 0% 20% 0% 10% 20% 0% Maximum Out-of-Pocket $1,200 / $2,400 $1,800 / $3,600 $2,250 / $4,500 $2,250 / $4,500 $1,700 / $3,400 $1,500 / $3,000 $1,750 / $3,500 $2,000 / $4,000 e-visits No Benefit $5 $3 $5 $3 $10 $10 $5 Office Visit Copay Deductible then $10 / $35 $5 / $25 $10 / $20 $5 / $15 $20 / $40 $15 / $30 $10 / $30 (PCP / Specialist) Urgent Care Copay Deductible then $35 $25 $20 $15 $40 $30 $30 Emergency Room Copay Deductible then $250 $250 $100 $75 $150 $150 $60 Mental Health Deductible then $10 $5 $10 $5 $20 $15 $10 Outpatient Copay Hospital Copay Deductible then $800 per diem / $1,500 per diem / Deductible then Deductible then Deductible then Deductible then Deductible then (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay Deductible then $5 / $50 / $2 / $30 / $4 / $26 / $4 / $26 / $4 / $26 / $10 / $30 / $4 / $26 / $100 / $200 $60 / $100 $60 / $200 $60 / $200 $60 / $200 $70 / $200 $60 / $200 Dental Coverage Available None* None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family for an Additional Charge? HSA Eligible? No No No No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product UH01448 (0715)

21 Unity Elite Network Cost Share Reduction Plans (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) 200% 250% of Federal Poverty Level Benefits Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Unity Elite Silver Deductible Maintenance Maintenance 30 / / / / / / / 70 Deductible (Single / Family) $1,500 / $3,000 $925 / $1,850 $750 / $1,500 $2,750 / $5,500 $4,000 / $8,000 $3,500 / $7,000 $2,600 / $5,200 $2,500 / $5,000 30% 0% 0% 30% 0% 20% 20% 0% Maximum Out-of-Pocket $3,250 / $6,500 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 $5,200 / $10,400 e-visits No Benefit $10 $15 $20 $10 $25 $15 $15 Office Visit Copay Deductible then $20 / $60 $25 / $65 $30 / $60 $20 / $55 $35 / $70 $20 / $40 $20 / $40 (PCP / Specialist) Urgent Care Copay Deductible then $60 $65 $60 $55 $70 $40 $40 Emergency Room Copay Deductible then $500 $500 $260 $150 $300 $200 $200 Mental Health Deductible then $20 $25 $30 $20 $35 $20 $20 Outpatient Copay Hospital Copay Deductible then $3,000 per diem / $3,000 per diem / Deductible then Deductible then Deductible then Deductible then Deductible then (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay Deductible then $5 / $60 / $5 / $60 / $10 / $30 / $10 / $30 / $4 / $26 / $10 / $50 / $10 / $50 / $120 / $200 $120 / $200 $70 / $200 $70 / $200 $60 / $200 $100 / $200 $100 / $200 Dental Coverage Available None* None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family None* or Family for an Additional Charge? HSA Eligible? Yes** No No No No No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01448 (0715)

22 Unity Elite Network Cost Share Reduction Plans (Adams, Crawford, Fond Du Lac, Grant, Green Lake, Juneau, Lafayette, Marquette, Richland, Rock, Vernon, Walworth and Waushara Counties) Optional Family Dental Adult Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 20% No Coverage $600 Benefit Maximum per Year dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage $600 Benefit Maximum per Year gingivectomy, dentures, implants and occlusal guards Orthodontics Not Covered Not Covered Not Covered Pediatric (up to age 19) Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 30% No Coverage No Benefit Maximum dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage No Benefit Maximum gingivectomy, dentures, implants and occlusal guards Orthodontics Covered only when medically necessary and a 24 month wait 50% coinsurance No Coverage No Benefit Maximum period is satisfied. UH01448 (0715)

23 Beloit One Network (Rock County) Platinum Plans These plans will cover about 90% of your service and you are responsible for the other 10% Benefits Beloit One Platinum 15 / 30 Deductible (Single / Family) $500 / $1,000 20% Maximum Out-of-Pocket $1,500 / $3,000 e-visits $10 Office Visit Copay (PCP / Specialist) $15 / $30 Urgent Care Copay $30 Emergency Room Copay $75 Mental Health Outpatient Copay $15 Hospital Copay (Inpatient / Outpatient) Deductible then Pharmacy Copay $10 / $25 / $50 / $200 Dental Coverage Available for an Additional Charge? None* or Family HSA Eligible? No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. UH01449 (0715)

24 Beloit One Network (Rock County) Gold Plans These plans will cover about 80% of your service and you are responsible for the other 20% Benefits Beloit One Gold 30 / 60 Deductible (Single / Family) $1,000 / $2,000 20% Maximum Out-of-Pocket $4,500 / $9,000 e-visits $20 Office Visit Copay (PCP / Specialist) $30 / $60 Urgent Care Copay $60 Emergency Room Copay $100 Mental Health Outpatient Copay $30 Hospital Copay (Inpatient / Outpatient) Deductible then Pharmacy Copay $10 / $25 / $50 / $200 Dental Coverage Available for an Additional Charge? None* or Family HSA Eligible? No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. UH01449 (0715)

25 Beloit One Network (Rock County) Silver Plans These plans will cover about 70% of your service and you are responsible for the other 30% Benefits Beloit One Silver Deductible Beloit One Silver 20 / 60 Beloit One Silver 40 / 90 Deductible (Single / Family) $2,000 / $4,000 $5,000 / $10,000 $4,000 / $8,000 30% 0% 50% Maximum Out-of-Pocket $4,900 / $9,800 $6,600 / $13,200 $6,600 / $13,200 e-visits No Benefit $10 $20 Office Visit Copay (PCP / Specialist) Deductible then $20 / $60 $40 / $90 Urgent Care Copay Deductible then $60 $90 Emergency Room Copay Deductible then $150 $300 Mental Health Outpatient Copay Deductible then $20 $40 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Pharmacy Copay Deductible then $10 / $30 / $70 / $200 $10 / $50 / $100 / $200 Dental Coverage Available None* None* or Family None* or Family for an Additional Charge? HSA Eligible? Yes** No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01449 (0715)

26 Beloit One Network (Rock County) Bronze Plans These plans will cover about 60% of your service and you are responsible for the other 40% Benefits Beloit One Beloit One Bronze HSA Bronze 55 / 150 Deductible (Single / Family) $5,400 / $10,800 $5,600 / $11,200 50% 20% Maximum Out-of-Pocket $6,400 / $12,800 $6,600 / $13,200 e-visits No Benefit $25 Office Visit Copay (PCP / Specialist) Deductible then $55 / $150 Urgent Care Copay Deductible then $150 Emergency Room Copay Deductible then $500 Mental Health Outpatient Copay Deductible then $55 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Pharmacy Copay Deductible then $20 / $60 / $120 / $200 Dental Coverage Available for an Additional Charge? None* None* or Family HSA Eligible? Yes** No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01449 (0715)

27 Beloit One Network (Rock County) Catastrophic Plans Only individuals under 30 years old or with a hardship exemption qualify for Catastrophic Plans Benefits Beloit One Catastrophic Deductible (Single / Family) $6,600 / $13,200 0% Maximum Out-of-Pocket $6,600 / $13,200 e-visits Office Visit Copay (PCP / Specialist) Urgent Care Copay Emergency Room Copay Mental Health Outpatient Copay Hospital Copay (Inpatient / Outpatient) Pharmacy Copay Dental Coverage Available for an Additional Charge? HSA Eligible? No Benefit $0** / Deductible then Deductible then Deductible then Deductible then Deductible then Deductible then None* No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. ** Only applies to the first three office visits with PCP then deductible then coinsurance applies. UH01449 (0715)

28 Beloit One Network (Rock County) Optional Family Dental Adult Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 20% No Coverage $600 Benefit Maximum per Year dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage $600 Benefit Maximum per Year gingivectomy, dentures, implants and occlusal guards Orthodontics Not Covered Not Covered Not Covered Pediatric (up to age 19) Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 30% No Coverage No Benefit Maximum dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage No Benefit Maximum gingivectomy, dentures, implants and occlusal guards Orthodontics Covered only when medically necessary and a 24 month wait 50% coinsurance No Coverage No Benefit Maximum period is satisfied. UH01449 (0715)

29 Beloit One Network Cost Share Reduction Plans (Rock County) % of Federal Poverty Level Benefits Beloit One Silver Deductible Beloit One Silver 20 / 60 Beloit One Silver 40 / 90 Deductible (Single / Family) $200 / $400 $300 / $600 $0 20% 0% 0% Maximum Out-of-Pocket $400 / $800 $525 / $1,050 $700 / $1,400 e-visits No Benefit $2 $2 Office Visit Copay (PCP / Specialist) Deductible then $3 / $10 $3 / $10 Urgent Care Copay Deductible then $10 $10 Emergency Room Copay Deductible then $40 $40 Mental Health Outpatient Copay Deductible then $3 $3 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Pharmacy Copay Deductible then $2 / $10 / $26 / $100 $2 / $10 / $26 / $100 Dental Coverage Available for an Additional Charge? None* None* or Family None* or Family HSA Eligible? No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. UH01450 (0715)

30 Beloit One Network Cost Share Reduction Plans (Rock County) % of Federal Poverty Level Benefits Beloit One Silver Deductible Beloit One Silver 20 / 60 Beloit One Silver 40 / 90 Deductible (Single / Family) $500 / $1,000 $1,000 / $2,000 $250 / $500 20% 0% 0% Maximum Out-of-Pocket $1,200 / $2,400 $1,700 / $3,400 $2,000 / $4,000 e-visits No Benefit $3 $5 Office Visit Copay (PCP / Specialist) Deductible then $5 / $15 $10 / $30 Urgent Care Copay Deductible then $15 $30 Emergency Room Copay Deductible then $75 $60 Mental Health Outpatient Copay Deductible then $5 $10 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Pharmacy Copay Deductible then $4 / $26 / $60 / $200 $4 / $26 / $60 / $200 Dental Coverage Available for an Additional Charge? None* None* or Family None* or Family HSA Eligible? No No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. UH01450 (0715)

31 Beloit One Network Cost Share Reduction Plans (Rock County) 200% 250% of Federal Poverty Level Benefits Beloit One Silver Deductible Beloit One Silver 20 / 60 Beloit One Silver 40 / 90 Deductible (Single / Family) $1,500 / $3,000 $4,000 / $8,000 $2,500 / $5,000 30% 0% 0% Maximum Out-of-Pocket $3,250 / $6,500 $5,200 / $10,400 $5,200 / $10,400 e-visits No Benefit $10 $15 Office Visit Copay (PCP / Specialist) Deductible then $20 / $55 $20 / $40 Urgent Care Copay Deductible then $55 $40 Emergency Room Copay Deductible then $150 $200 Mental Health Outpatient Copay Deductible then $20 $20 Hospital Copay (Inpatient / Outpatient) Deductible then Deductible then Deductible then Pharmacy Copay Deductible then $10 / $30 / $70 / $200 $10 / $50 / $100 / $200 Dental Coverage Available for an Additional Charge? None* None* or Family None* or Family HSA Eligible? Yes** No No Please contact your insurance carrier, agent or the Federally Facilitated Exchange if you wish to purchase pediatric dental coverage or a standalone dental services product. ** For HSA Eligible Family Plans, the single deductible and maximum-out-of-pocket limits listed do not apply. An individual family member may accumulate to the entire family deductible and maximum-out-of-pocket limits listed. UH01450 (0715)

32 Beloit One Network Cost Share Reduction Plans (Rock County) Optional Family Dental Adult Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 20% No Coverage $600 Benefit Maximum per Year dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage $600 Benefit Maximum per Year gingivectomy, dentures, implants and occlusal guards Orthodontics Not Covered Not Covered Not Covered Pediatric (up to age 19) Benefits In-Network Out-Of-Network Benefit Maximum Cleanings / x-rays (Class A) Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and 100% Coverage No Coverage 1 visit per 6 months space maintainers Basic Restorative (Class B) Includes fillings, re-cementing of crowns, prefab crowns for members under age 15, endodontic services and repair / adjust / replacement of 30% No Coverage No Benefit Maximum dentures and oral surgery procedures such as wisdom tooth or other tooth Benefit limits may apply to posterior composite fillings; age limits may apply to certain procedures. Major Restorative (Class C) Includes such services as crowns, root canals, apicoectomy, 50% No Coverage No Benefit Maximum gingivectomy, dentures, implants and occlusal guards Orthodontics Covered only when medically necessary and a 24 month wait 50% coinsurance No Coverage No Benefit Maximum period is satisfied. UH01450 (0715)

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