CATEGORY AFSCME Comprehensive Plan OU PPO

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1 APPENDIX B BENEFIT PLAN SUMMARY CHART CATEGORY AFSCME Comprehensive Plan OU PPO Premiums Plan Year Plan Year Annual Wages: $0 - $34,600 $13.50 EE only $24.00 EE + Child $24.00 EE + Spouse $35.00 EE + Family Annual Wages: $0 - $34,600 $13.50 EE only $24.00 EE + Child $24.00 EE + Spouse/Domestic Partner $35.00 EE + Family Annual Wages: $34,601 + $16.50 EE Only $28.00 EE + Child $28.00 EE + Spouse $42.00 EE + Family Annual Wages: $34,601 + $16.50 EE Only $28.00 EE + Child $28.00 EE + Spouse/Domestic Partner $42.00 EE + Family In-Network Out-of-Network Deductible Based on Salary Yr 1 $100/$200 $400/$800 <$20,000 = $100/$200 Yr 2 $150/$300 no change $20-$29,999 = $150/$300 Yr 3 $200/$400 no change $30-$39,999 = $200/$400 individual/family individual/family $40-$49,999 = $250/$500 and so on... Plan Co-Insurance see each category (% shown unless otherwise noted) 80% for co-insurance level Employee Co-Insurance 20% see each category for co-insurance level Employee Plan Year Out-of-Pocket Maximum Yr 1 $550/$1,100 $1500/$3000 (Equals total employee co-insurance for plan year. Yr 2 $650/$1,300 no change Does not include deductible, co-pays, services $500/$1000 Yr 3 $750/$1,500 no change for outpatient mental health/substance abuse or individual/family individual/family individual/family employee contributions.) employee out-of-pocket maximums accumulate separately; therefore, charges for out-of-network services cannot be applied to the in-network employee out-ofpocket maximum and vice versa Individual Lifetime Maximum Benefit $1,000,000 $3,000,000 unless otherwise specified Pre-Existing Condition Limitations None None OFFICE VISITS (including specialists) Office visit for injury or illness subject to ded.- 80% reimb. no ded. - $20 Co-pay subject to ded. - 70% reimb. Office visit for psychiatric medication management subject to ded.- 80% reimb. no ded. - $20 Co-pay subject to ded. - 70% reimb. PREVENTIVE CARE No ded - 80% reimb. No deductible No ded. - 70% reimb. (see plan document for procedures covered and 100% reimbursement for $20 co-pay for office visit coverage guidelines; see end of chart for examples.) eligible procedures 100% reimbursement for eligible procedures Child Health Supervision Office Visit charges apllied to deductible No deductible No ded. - 70% reimb. (see plan document for age intervals 100% reimb. for other $20 Co-pay for office visit and dollar maximums) procedures up to dollar 100% reimb. for other maximums at each age interval procedures up to dollar maximums at each age interval MAMMOGRAMS - Preventive and Diagnostic Preventive: No ded.- 100% No ded % reimb. No ded. - 70% reimb. Diagnostic: Ded.- 80% (office visit subject to deductible) GYNECOLOGICAL EXAMS/PAP SMEARS Preventive: No ded.- 100% $20 Co-pay for office visit No ded. - 70% reimb. Preventive and Diagnostic Diagnostic: Ded.- 80% (office visit subject to deductible) OUTPATIENT SERVICES subject to ded.- 80% reimb. subject to ded. - 90% reimb. subject to ded. - 70% reimb. (non-emergency lab, x-ray, diagnostic testing and First $100 in lab/xray/diag preadmission testing, allergy injections, serums, and preadmission testing

2 medically necessary colonoscopies, etc.) paid at 100% Provider may need to obtain precertification per Pre-cert. Required for insurance company standards. procedures over $500 SURGERY (inpatient, outpatient, doctor's office & other) subject to ded- 80% reimb. subject to ded. - 90% reimb. subject to ded. - 70% reimb. Precertification required SECOND SURGICAL OPINION no ded.- 100% reimb. subject to ded. - 90% reimb. paid as in-network HOSPITAL SERVICES 1st $1,000 (inpt.) is subject to ded. - 90% reimb. subject to ded. - 70% reimb. reimb. 100% Afterwards subject to ded. and 80% reimb. EMERGENCIES subject to ded- 80% reimb. $75 co-pay paid as in-network A medical emergency is defined by insurance Accidents: 100% for first deductible and co-insurance company standards. May include a condition that 48 hours apply thereafter if untreated could be life threatening or seriously impair bodily functions URGENT CARE FACILITY subject to ded- 80% reimb. $20 co-pay subject to ded. - 70% reimb. TRANSPLANTS subject to ded- 80% reimb Special benefits exist for transplants; up to 100% coverage (Transplant program is available.) (However, 100% coverage is available if is available in certain circumstances; see plan official in certain circumstances; see plan official plan documents. plan documents) AMBULANCE subject to ded- 80% reimb. subject to ded. - 80% reimb. paid as in-network (subject to medical necessity) EXTENDED CARE FACILITY SERVICES/ subject to ded.- 80% reimb. subject to ded. - 80% reimb. paid as in-network SKILLED NURSING FACILITY Precertification and prior hospitalization required. Large case management available HOSPICE SERVICES Precertification required. Inpatient subject to ded- 80% reimb. subject to ded. - 80% reimb. paid as in-network In Lieu of Hospitalization no ded.- 100% reimb. subject to ded % reimb paid as in-network HOME HEALTH CARE SERVICES subject to ded- 80% reimb subject to ded. - 80% reimb. paid as in-network Annual maximum applies to total number of max= 100 visits/ plan yr. home health services. max eligible expense= $40 In Lieu of Hospitalization no ded.- 100% reimb subject to ded % reimb. paid as in-network max of 100 visits/ plan yr. DURABLE MEDICAL EQUIPMENT subject to ded.- 80% reimb. subject to ded. - 80% reimb. paid as in-network PHYSICAL THERAPY Inpatient subject to ded- 80% subject to ded. - 90% reimb. subject to ded. - 70% reimb. Outpatient subject to ded.- 80% $20 co-pay subject to ded. - 70% reimb. OCCUPATIONAL THERAPY Inpatient subject to ded.- 80% reimb. subject to ded. - 90% reimb. subject to ded. - 70% reimb. Outpatient subject to ded- 80% reimb $20 co-pay subject to ded. - 70% reimb. SPEECH THERAPY Inpatient subject to ded.- 80% reimb. subject to ded. - 90% reimb. subject to ded. - 70% reimb. Outpatient subject to ded.- 80% reimb. $20 co-pay subject to ded. - 70% reimb. CHIROPRACTIC SERVICES subject to ded- 80% reimb $20 co-pay subject to ded. - 70% reimb.

3 TMJ subject to ded.- 80% reimb. subject to ded. - 80% reimb. paid as in-network for $1500 lifetime maximum for non-surgical TMJ covered non-surgical TMJ covered services services HEARING Non deductible Subject to deductible paid as in-network $40 for otologic exam and $40 for hearing exam and $400 for services/ equip. $600 for services/equipment every 48 months every 36 months MATERNITY Pre and postnatal physician services subject to ded.- 80% $20 co-pay for first visit; subject to ded. - 70% reimb. afterwards 90% reimb. Delivery: Vaginal & Cesarean subject to ded.- 80% subject to ded - 90% reimb. subject to ded. - 70% reimb. Lab & Radiology subject to ded.- 80% subject to ded - 90% reimb. subject to ded. - 70% reimb. MENTAL HEALTH Inpatient subject to ded- 80% reimb. subject to ded. - 90% reimb. subject to ded. - 70% reimb. Precertification required. Outpatient Counseling First 5 visits of plan year First 5 visits of plan year First 5 visits of plan year Precertification required. No deductible No deductible No deductible Through EAP - 100% reimb. Through EAP - 100% reimb. 70% Not through EAP 70% reimb. Not Through EAP $20 copay Remaining 45 visits Remaining visits Remaining 45 visits No deductible $20 copay No deductible 70% paid at 50% SUBSTANCE ABUSE Inpatient subject to ded- 80% reimb. subject to ded. - 90% reimb. subject to ded. - 70% reimb. Precertification required. 2 confinements per lifetime 2 confinements/lifetime Outpatient Counseling First 5 visits of plan year First 5 visits of plan year First 5 visits of plan year Precertification required. No deductible No deductible No deductible Through EAP - 100% reimb. Through EAP - 100% reimb. 70% Not through EAP 80% reimb. Not through EAP 70% reimb. Remaining 45 visits Remaining 45 visits Remaining 45 visits No deductible No deductible No deductible 80% 70% paid at 50% Vision is currently administered by Vision Service Plan (VSP). Vision is currently administered by Vision Service Plan (VSP). Vision The administrator is subject to change. The administrator is subject to change. (regardless of health plan chosen) VSP pays for 1 exam, lenses or contact lenses, and frames VSP pays for 1 exam, lenses or contact lenses, and frames every 24 months for adults and 12 months for a dependent every 24 months for adults and 12 months for a dependent child. The reimbursement level for benefits child. The reimbursement level for benefits depends on VSP's agreement with the provider. depends on VSP's agreement with the provider. Employee Dental (regardless of health plan chosen) Dependent Dental Employee Orthodontia no deductible no deductible Dependent Orthodontia Prescription Plan (formulary list is maintained and controlled by prescription benefit management company (PBM) and is subject to changes as directed by PBM) See Article 38 for Drug Copays See Article 38 for Drug Copays

4 Employer Provided Life Insurance $24,000 Term Life (additional $24,000 for accidental death) 2.5 times annual pay to a maximum of $50,000 Supplemental Employee Paid Life Insurance Up to $100,000 available Life insurance company premiums and rules regarding eligibility, enrollment amounts, approval, and payment of benefits apply. Up to $500,000 available Life insurance company premiums and rules regarding eligibility, enrollment amounts, approval, and payment of benefits apply. Supplemental Employee Paid Dependent Life Up to $10,000 for spouse and $5,000 Insurance per child available per life insurance company premiums, options, and eligibility rules Up to $20,000 for spouse and $10,000 per child available per life insurance company premiums, options, and eligibility rules Long Term Disability None 60% of pay available from disability insurance company on approval of application (OPERS Disability Retirement available per OPERS eligibilty rules) (OPERS Disability Retirement available per OPERS eligiblity rules) Preventive Care Examples See Plan Book for All Details regarding Preventive Care Coverage The following are paid at 100% of allowed charges when billed as preventive/routine. Office visits charges related to these services are subject to plan deductibles, co-insurance, copays, etc.: - Routine Physical Exam - Tetanus Vaccine - Hepatitis B Vaccine - HIV Screening - Total Cholesterol Screening - Prostrate Specific Antigen and Digital Rectal Exam - Pneumococcal - Once for ages 65 and older - Electrocardiograph Stress Test - Thyroid Panel - Diabetes Screening - Sigmoidoscopy - Mammograms - see plan chart/book - GYN exams/pap tests (including pap CA 125)- see plan chart/book - Colonoscopy - Lipid Panel - Gardisil Vaccine (HPV related diseases such as cervical cancer) - Venipuncture Well Child Care: Total plan benefits of $2,400 from birth up to age 2 years. $900 for ages 2 up to age 9. See chart above for In-Network and Out-of-Network Coverage Levels (copays; deductibles; etc. that apply) Preventive Care benefits may vary based on the age, sex, and personal history of the individual, and as determined appropriate by the Administrator's clinical coverage guidelines. Screenings and other services are generally covered as Preventive Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service. Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Preventive Care for that condition but instead benefits will be considered under the Diagnostic Services benefit. Examples of of Preventive Care Covered Service are: -Routine or periodic exams, including school enrollment physical exams -Well baby and well-child, including child health supervision services, based on American Academy of Pediatric Guidelines - Child health supervision includes but is not limited to, a review of a child's physical and emotional status performed by a Physician, by a health care rofessional under the supervision of a Physician, in accordance with the recommendations of the American Academy of Pediatrics and includes a his - Adult routine physical examinations - Pelvic examinations - Routine EKG, Chest XR, laboratory tests such as complete blood count, comprehensive metabolic panel, urinalysis. - Annual dilated eye examination for diabetic retinopathy - Immunizations Immunizations (including those required for school), following the current Childhood and Adolescent Immunization Schedule as approved by the Advisory Committee on Immunization Practice (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). For adults, the Plan follows the Adult Immunization Schedule by age and medical condition as approved by the Advisory Committee on Immunization Practice (ACIP) and accepted by the American College of Gynecologists (ACOG) and the American Academy of Family Physicians. These include, but are not limited to: - Hepatitis A; Hepatitis B; Hib; Influenza virus vaccine; Rabies vaccine; Diptheria, Tetanus, and Pertusses vaccine; Mumps vaccine, Measles vaccine; Rubella vaccine; Poliovirus vaccine; Gardisil -Screening examinations include by may not be limited to: 1. Routine vision screenings for disease or abnormalities 2. Routine hearing screenin 3. Routine screening mammograms 4. Routine cytologic and chlamydia screening (including pap test) 5. Routine bone density testing for women 6. Routine prostate specific antigen testing 7. Routine colorectal cancer examination and related laboratory tests. Exam

5 Diabetes self management training is covered for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition when: Medically Necessary; Ordered in writing by a Physician or a podiatrist; and Provided by a Health Care Professional who is licensed, registered, or certified under state law. For the purposes of this provision, a ""Health Care Professional"" means the Physician or podiatrist ordering the training or a Provider who has obtained certification in diabetes education by the American Diabetes Association.

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