Pace University CIGNA Medical Detailed Benefit Summaries July 1, June 30, 2016

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1 Consumer Core HDHP In Net $50 (ONLY APPLICABLE TO THOSE Network Core $25 ALREADY ENROLLED) Network Choice Fund In Network In Network In Network Deductible $1,300/$2,600 (Cumulative) N/A N/A Coinsurance 90% N/A N/A Out of Pocket Maximum $2,500/$5,000 (Cumulative) $5,000/$10,000 $2,000/$4,000 Annual Maximum, Unless noted otherwise Unlimited Unlimited Unlimited Lifetime Maximum, Unless Unlimited Unlimited Unlimited noted otherwise Prescription Drugs Mail Order Prescription Drugs (Three (3) month Supply) Deductible and then 20%/30%/40% Coinsurance up to the Out of Pocket Maximum 3x Discounted Retail (see above) $20/$40/$80 ($125/$375 Deductible - waived for generic) Same copay as retail $15/$30/$55 ($125/$375 Deductible - waived for generic) Same copay as retail Pharmacy Maximum Out of Pocket Combined with medical $1,600/$3,200 $4,000/$8,000 Oral Contraceptive Coverage Included Included Included PCP Office Visits Deductible and Coinsurance $50 $25 Specialist Visits Deductible and Coinsurance $50 $25 OB/GYN Visits Deductible and Coinsurance Preventive care - Covered $50 copay Preventive care - Covered $25 copay Preventive care - Covered Routine Preventive Care (adult) ; ; ; Well Child Exams (through age 18) ; ; ; Vision Coverage- Active Employees Only Separate vision plan through CIGNA Vision Separate vision plan through CIGNA Vision Separate vision plan through CIGNA Vision Gym Reimbursement Discounts available through Healthy Rewards Discounts available through Healthy Rewards Discounts available through Healthy Rewards Lab and X-ray Participating lab - Participating lab - Office visit - $50 copay (No charge if only lab/xray services performed and billed) ray services performed and billed) Office visit - $25 copay (No charge if only lab/x- Outpatient - Outpatient -

2 Consumer Core HDHP In Net $50 (ONLY APPLICABLE TO THOSE Network Core $25 ALREADY ENROLLED) Network Choice Fund In Network In Network In Network Advanced Radiology Chiropractic Ambulance Service Office Visit - $50 (no charge if only radiology services performed and billed) Outpatient - $50 Office Visit - $25 (no charge if only radiology services performed and billed) Outpatient - $25 (when Medically necessary) (when Medically necessary) Emergency Room $155 per visit; Waived if admitted $80 per visit; Waived if admitted Urgent Care $55 per visit; Waived if admitted $25 per visit; Waived if admitted Hospitalization $500 per day copay; annual max $2,500 then Outpatient Surgery $500 Copay Inpatient Mental Health Unlimited day maximum per calendar $500 per day copay; annual max $2,500 Unlimited day maximum per calendar Unlimited day maximum per calendar Outpatient Mental Health Office Visit - $50 copay Outpatient Facility - Outpatient Facility - Substance Abuse Inpatient - $500 per day copay; annual max $2,500 then Office Visit - $50 Copay Outpatient Facility - Inpatient - ; Office Visit - $25 Copay Outpatient Facility - Inpatient Physical Therapy 60 days maximum per calendar includes Skilled Nursing Facility, Rehabilitation Hospital, Sub Acute $500 per day copay; annual max $2,500 then ; 60 days per calendar includes Skilled Nursing, Rehabilitation Hospital and Sub Acute ; 60 days per calendar includes Skilled Nursing, Rehabilitation Hospital and Sub Acute

3 Consumer Core HDHP In Net $50 (ONLY APPLICABLE TO THOSE Network Core $25 ALREADY ENROLLED) Network Choice Fund In Network In Network In Network Outpatient Physical Therapy 90 days combined maximum per calendar Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab, Cognitive Therapy $50 Copay; 90 days combined maximum per calendar. Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab, Cognitive Therapy $25 Copay; 90 days combined maximum per calendar. Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab, Cognitive Therapy Hospice Care Home Health Care (includes Outpatient Private Duty Nursing) ; Unlimited days maximum per calendar yr; ; Unlimited days maximum per calendar yr; ; Unlimited days maximum per calendar yr; Skilled Nursing Facility TMJ- Surgical and Non Surgical - Always excludes appliances & orthodontic treatment. Subject to medical necessity. Infertility Abortion ; Includes Rehabilitation Hospital and Sub-Acute Basic (includes artificial insemination) - No Max. Advanced Infertility ( IV, ZIFT, GIFT) - $10,000 Lifetime Max Includes Rehabilitation Hospital and Sub-Acute Office visit - $50 copay Inpatient - $500 copay per day (annual max $2,500) Outpatient $500 Copay Office visit - $50 copay Inpatient - $500 copay (annual max $2,500) Outpatient - $500 copay Basic (includes artificial insemination) - No Max. Advanced Infertility ( IV, ZIFT, GIFT) - $10,000 Lifetime Max Office visit - $50 copay Inpatient - $500 copay (annual max $2,500) Outpatient - $500 copay Includes Rehabilitation Hospital and Sub-Acute Office visit - $25 copay Inpatient and Outpatient facility -. Inpatient & Outpatient Facility - Basic (includes artificial insemination) - No Max. Advanced Infertility ( IV, ZIFT, GIFT)- $10,000 Lifetime Max Inpatient & Outpatient Facility - Dependent Age 26, End of calendar yr 26, End of calendar yr 26, End of calendar yr

4 Consumer Core HDHP In Net $50 (ONLY APPLICABLE TO THOSE Network Core $25 ALREADY ENROLLED) Network Choice Fund In Network In Network In Network Durable Medical Equip. Out of Network Reasonable & Customary Pre-certification required Penalty for Failure to Pre-certify ; ; ; N/A N/A N/A Yes, coordinated by provider/pcp Yes, coordinated by provider/pcp Yes, coordinated by provider/ PCP N/A N/A N/A *Many of the above services may require precertification through CIGNA. Day & Visit limits are combined both in and out of network. Please confirm with CIGNA **The benefit summaries shown above do not replace the official plan documents or contracts that govern your eligibility to participate in these plans or the amount of benefits you may receive. If there is a discrepancy between the official plan documents and this summary, your actual benefits will always be governed by the plan documents.

5 Network Deductible Coinsurance Out of Pocket Maximum Annual Maximum, Unless noted otherwise Lifetime Maximum, Unless noted otherwise Prescription Drugs Mail Order Prescription Drugs (Three (3) month Supply) Pharmacy Maximum Out of Pocket Oral Contraceptive Coverage PCP Office Visits Specialist Visits OB/GYN Visits Routine Preventive Care (adult) Well Child Exams (through age 18) Vision Coverage- Active Employees Only Gym Reimbursement Lab and X-ray In Network Out of Network In Network Out of Network $250/$500 $1,200/$2,400 N/A $1,200/$2,400 90% 70% N/A 70% $1,200/$2,400 $2,500/$5,000 $1,750/$3,500 $2,500/$5,000 Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited $15/$30/$55 ($125/$375 Deductible - waived for generic) 30% Coinsurance ($125/$375 Deductible - waived for generic) $15/$30/$55 ($125/$375 Deductible - waived for generic) 30% Coinsurance ($125/$375 Deductible - waived for generic) Same copay as retail In-Network Benefit Only Same copay as retail In-Network Benefit Only $4,000/$8,000 $4,000/$8,000 $4,000/$8,000 $4,000/$8,000 Included Included Included Included $25 $15 $25 $20 $25 copay Preventive care - Covered ; ; Network Choice 90/70 ; ; Separate vision plan through CIGNA Vision Discounts available through CIGNA Healthy Rewards Program Participating lab - Office visit - $25 copay (No charge if only lab/x-ray services performed and billed) Outpatient - 100/70 Plan (ONLY APPLICABLE TO THOSE ALREADY ENROLLED) $15 or $20 copay Preventive care - Covered ; ; ; ; Separate vision plan through CIGNA Vision Discounts available through CIGNA Healthy Rewards Program Participating lab - Office visit - $15/$20 copay (No charge if only lab/x-ray services performed and billed) Outpatient -

6 Network Advanced Radiology Chiropractic Ambulance Service Emergency Room Urgent Care Hospitalization Outpatient Surgery Inpatient Mental Health Outpatient Mental Health Network Choice 90/70 100/70 Plan (ONLY APPLICABLE TO THOSE ALREADY ENROLLED) In Network Out of Network In Network Out of Network Office Visit - $25 (no charge if only radiology services performed and billed) Outpatient - Deductible & Coinsurance $25 Office Visit - $15/$20 (no charge if only radiology services performed and billed) Outpatient - $20 Deductible & 10% Coinsurance (when Medically Necessary) (when Medically Necessary) $80, Waived if admitted $80, Waived if admitted $80, Waived if admitted $80, Waived if admitted $25; Waived if admitted $25; Waived if admitted $25; Waived if admitted $25; Waived if admitted Unlimited day maximum per calendar Unlimited day maximum per calendar Unlimited day maximum per calendar Unlimited day maximum per calendar Outpatient Facility - Deductible & Coinsurance Office Visit - $20 copay Outpatient Facility - Substance Abuse Inpatient Physical Therapy Inpatient - Deductible & Coinsurance; Outpatient Facility - Deductible & Coinsurance ; 60 days per calendar includes Skilled Nursing, Rehabilitation Hospital and Sub Acute ; ; 60 days per calendar includes Skilled Nursing, Rehabilitation Hospital and Sub Acute Inpatient - Office Visit - $20 copay Outpatient Facility - ; 60 days per calendar includes Skilled Nursing, Rehabilitation Hospital and Sub Acute ; ; 60 days per calendar includes Skilled Nursing, Rehabilitation Hospital and Sub Acute

7 Network Outpatient Physical Therapy Hospice Care Home Health Care (includes Outpatient Private Duty Nursing) Skilled Nursing Facility TMJ- Surgical and Non Surgical - Always excludes appliances & orthodontic treatment. Subject to medical necessity. Infertility Abortion Dependent Age $25 Copay; 90 days combined maximum per calendar. Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab, Cognitive Therapy Network Choice 90/70 100/70 Plan (ONLY APPLICABLE TO THOSE ALREADY ENROLLED) In Network Out of Network In Network Out of Network $20 Copay; ; 90 days combined maximum per 90 days combined maximum per calendar. Includes: Cardiac calendar. Includes: Cardiac Rehab, Physical Therapy, Speech Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Therapy, Occupational Therapy, Pulmonary Rehab, Cognitive Pulmonary Rehab, Cognitive Therapy Therapy ; $50, plan deductible does not apply. Unlimited days maximum per calendar yr; Includes Rehabilitation Hospital and Sub-Acute Office visit - $25 copay Inpatient and Outpatient facility - Inpatient & Outpatient Facility - Basic (includes artificial insemination) - No Max. Advanced Infertility ( IV, ZIFT, GIFT)- $10,000 Lifetime Max Inpatient & Outpatient Facility - ; 75% after $50 Deductible, plan deductible does not apply yr; Includes Rehabilitation Hospital and Sub-Acute ; Basic (includes artificial insemination) - No Max. Advanced Infertility ( IV, ZIFT, GIFT)- $10,000 Lifetime Max ; Unlimited days maximum per calendar yr; Includes Rehabilitation Hospital and Sub-Acute Office visit - $15/$20 (PCP or Specialist) copay; Inpatient and Outpatient facility -. Office Visit - $15/20 copay Inpatient & Outpatient Facility - Basic (includes artificial insemination) - No Max. Advanced Infertility ( IV, ZIFT, GIFT)- $10,000 Lifetime Max Office Visit - $15/20 copay Inpatient & Outpatient Facility - ; 90 days combined maximum per calendar. Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab, Cognitive Therapy ; 75% after $50 Deductible, plan deductible does not apply yr; Includes Rehabilitation Hospital and Sub-Acute ; Basic (includes artificial insemination) - No Max. Advanced Infertility ( IV, ZIFT, GIFT)- $10,000 Lifetime Max 26, End of calendar yr 26, End of calendar yr 26, End of calendar yr 26, End of calendar yr

8 Network Durable Medical Equip. Out of Network Reasonable & Customary Pre-certification required Penalty for Failure to Pre-certify Network Choice 90/70 100/70 Plan (ONLY APPLICABLE TO THOSE ALREADY ENROLLED) In Network Out of Network In Network Out of Network ; ; ; ; N/A 300% of Medicare N/A 300% of Medicare Yes, coordinated by provider/ PCP Yes, EE responsible Yes, coordinated by provider/ PCP Yes, EE responsible N/A Lesser of 50% or $500 penalty applied to hospital inpatient charges for failure to contact CIGNA Healthcare to precertify admission. Benefits are denied for any admission reviewed by CIGNA Healthcare and not certified. Benefits are denied for any additional days not certified by CIGNA Healthcare. N/A Lesser of 50% or $500 penalty applied to hospital inpatient charges for failure to contact CIGNA Healthcare to precertify admission. Benefits are denied for any admission reviewed by CIGNA Healthcare and not certified. Benefits are denied for any additional days not certified by CIGNA Healthcare. *Many of the above services may require precertification through CIGNA. Day & Visit limits are combined both in and out of network. Please confirm with CIGNA **The benefit summaries shown above do not replace the official plan documents or contracts that govern your eligibility to participate in these plans or the amount of benefits you may receive. If there is a discrepancy between the official plan documents and this summary, your actual benefits will always be governed by the plan documents.

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