UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits

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1 UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits Please refer to your Provider Directory for listings of Participating Physicians, Hospitals, and other Providers. Deductibles and Maximums Deductible (Contract Period) Individual $2,000 $4,000 Family $4,000 $8,000 All individual Deductible amounts will count toward the family Deductible, but an individual will not have to pay more than the individual Deductible amount. The Deductible and Deductible are separate. Maximum Out-of-Pocket Expense (Contract Period) (includes Copayments, Coinsurance, and Deductibles) Individual $6,250 $12,000 Family $12,500 $24,000 All individual Maximum Out-of-Pocket amounts will count toward the family Maximum Out-of-Pocket Expense, but an individual will not have to pay more than the individual Maximum Out-of-Pocket Expense. The Maximum Out-of-Pocket Expense and Maximum Out-of-Pocket Expense are separate. Pharmacy cost sharing applies towards the Maximum Out-of- Pocket. Please note: In the event that UnitedHealthcare is unable to reasonably meet your need for services through our Participating Provider Network, you may seek preauthorized Covered Health Services from a Non-, and you will be entitled to full reimbursement. Benefits for Covered Services Preventive Care Services ( Preventive Care refers to examinations and services recommended by the U.S. Preventive Services Task Force or preventive care services mandated by state or federal law or regulation.) Physical Exams/Well-Child Care Covered at 100%. 70% of Allowed Charge after Deductible Immunizations Covered at 100%. 70% of Allowed Charge after Deductible Laboratory and X-ray Covered at 100%. 70% of Allowed Charge after Deductible Physician Office Services Office Visits, including diagnosis of infertility 100% after you pay a Copayment of $30 does Office Surgery 100% after you pay a Copayment of $30 does Allergy Testing 100% after you pay a Copayment of $30 does Allergy Injections 70% of Allowed Charge. Deductible does Other Injections 70% of Allowed Charge. Deductible does Maternity Physician Services 70% of Allowed Charge after Deductible Newborn Services Inpatient Outpatient See Physician Services at a Facility other than the Office, Facility Services, or other applicable. See Physician Services at a Facility other than the Office, Facility Services, or other applicable.

2 Benefits for Covered Services Physician Services at a Facility other than the Office Home Visits 100% after you pay a Copayment of $30 does Inpatient Facility Visits 70% of Allowed Charge after Deductible Outpatient Facility Visits 70% of Allowed Charge after Deductible Inpatient Surgery 70% of Allowed Charge after Deductible Outpatient Surgery 70% of Allowed Charge after Deductible Emergency Services (Follow-up care obtained in the emergency room is not covered.) Benefits for Emergency Health Services are provided to the extent necessary to screen and to stabilize the Covered Person. Emergency Room Physician 100% of Allowed Charge. Deductible does Covered the same as Services Emergency Room 100% after you pay a Copayment of $250 Covered the same as Services per visit for initial care only of a Medical Emergency. Deductible does Emergency Room Copayment waived if admitted. Physician s services or other services separately charged may require a separate Copayment and/or Coinsurance in addition to any applicable Deductible, beyond the emergency room facility charge. Urgent Care Facility 100% after you pay a Copayment of $100 per visit. Deductible does Ambulance Services 70% of Allowed Charge after Deductible. Non-emergency transports must be approved in advance by UnitedHealthcare. 70% of Allowed Charge after Deductible. Non-emergency transports must be approved in advance by UnitedHealthcare. Laboratory, X-ray and Other Diagnostic Testing Outpatient 70% of Allowed Charge after Deductible Office 100% of Allowed Charge. Deductible does Major Diagnostics (MRI, MRA, CAT and PET Scans) 70% of Allowed Charge after Deductible Note X-ray and laboratory services separately charged by an independent laboratory may require separate Coinsurance and/or Deductible, beyond the physician s office Copayment, Coinsurance and/or Deductible. Chemotherapy, Radiation Therapy, Renal Dialysis Services Hospital (Outpatient) 70% of Allowed Charge after Deductible Office 70% of Allowed Charge. Deductible does

3 Benefits for Covered Services Facility Services Inpatient Facility (2) 70% of Allowed Charge after Deductible Please note: Prior benefit confirmation is not required for minimum hospital stay following childbirth. Outpatient Facility 70% of Allowed Charge after Deductible Skilled Nursing Facility (2) - 70% of Allowed Charge after Deductible (Member is limited to 100 days per Contract Period. The 100 and days are combined.) Medical Equipment (Diabetic supplies do not count toward the Durable Medical Equipment benefit maximum.) Durable Medical Equipment (2) 70% of Allowed Charge after Deductible Prosthetic Devices (2) 70% of Allowed Charge after Deductible Hearing Aid Devices (2) 70% of Allowed Charge after Deductible (For Covered Persons age 22 and over, Plan pays a maximum benefit of $2,500 per Contract Period. For Covered Persons under the age of 22, no dollar limits apply, and Plan covers a minimum of one hearing aid per ear every 36 months.) Outpatient Rehabilitative Therapy Outpatient Rehabilitative Therapy includes physical, speech, and occupational therapy and cardiac (Phase I and II) and pulmonary rehabilitation. (Member is limited to 60 outpatient treatment visits per Contract Period. The and visits are combined.) 100% after you pay a Copayment of $30 per visit. Deductible does Home Health Services (2) 70% of Allowed Charge after Deductible Hospice Services (2) 70% of Allowed Charge after Deductible Respite Care (2) 70% of Allowed Charge after Deductible Organ and Tissue Transplants (2) Covered as any other medical condition. See Physician Office Services, Physician Services at a Facility other than the Office, Facility Services, or other applicable Cornea Transplants Clinical Trials Temporomandibular Joint Services (2) Mental Health Services Inpatient Facility (2) 70% of Allowed Charge after Deductible Inpatient Physician Visits (2) 70% of Allowed Charge after Deductible Outpatient Facility (2) 70% of Allowed Charge after Deductible Outpatient Physician Services (2) 70% of Allowed Charge after Deductible per visit. Deductible does

4 Benefits for Covered Services Substance Abuse Services Inpatient Facility (2) 70% of Allowed Charge after Deductible Inpatient Physician Visits (2) 70% of Allowed Charge after Deductible Outpatient Facility (2) 70% of Allowed Charge after Deductible Outpatient Physician Services (2) 70% of Allowed Charge after Deductible per visit. Deductible does Neurobiological Disorders - Autism Spectrum Disorder Services Inpatient Facility (2) 70% of Allowed Charge after Deductible Inpatient Physician Visits (2) 70% of Allowed Charge after Deductible Outpatient Facility (2) 70% of Allowed Charge after Deductible Outpatient Physician Services (2) 70% of Allowed Charge after Deductible per visit. Deductible does Dental - Anesthesia and Hospital or Facility Charges Lymphedema Services Coverage Limitations: Services at a Facility other than the Office, Facility Services or other applicable. Services at a Facility other than the Office, Facility Services or other applicable. (1) For services from Non-s, the Allowed Charge is the Maximum Non-Network Reimbursement Program (MNRP). Except when services were rendered in a Medical Emergency [or when services are rendered by a nonparticipating facility-based provider (a physician or other provider who provide radiology, anesthesiology, pathology, neonatology, or emergency department services) at a participating facility or participating ambulatory surgical center, the Member is responsible for paying any amounts exceeding the MNRP for services received from Non-Participating Providers. Such excess amounts will not count toward the Deductible or Maximum Out-of-Pocket Expense. (2) Services require Preauthorization. When a Member uses s, the is responsible for obtaining Preauthorization. When a Member uses Non-s, the Member is responsible for obtaining Preauthorization from UnitedHealthcare (or for mental health and substance abuse services, from UnitedHealthcare s mental health and/or substance abuse treatment program provider). If the Member fails to obtain Preauthorization for Covered Services from Non-s, the Member will pay a Penalty of an additional 10 percentage points in his or her Coinsurance. The Penalty amount paid by the Member will not exceed $1,000, and it will not count toward the Deductible or Maximum Out-of-Pocket Expense. Note: Your actual expense for covered health care services may exceed the stated coinsurance percentage or copayment amount because actual provider charges may not be used to determine plan or insured payment obligations. Continuity of Care This continuity of care provision applies to you if either of the following is true: You have an ongoing special condition and the Network provider from whom you are receiving care loses his/her status as a Network provider and becomes a Non-Network provider (for reasons other than those relating to quality of care or fraud). We will notify you on a timely basis that the provider is no longer a Network provider and of your right to elect continuation of coverage with that provider. You are newly a Covered Person because your employer has changed health benefit plans and you have an ongoing special condition for which you are receiving treatment from a Non-Network Provider. We will notify you on the date of enrollment of the right to elect continuation of coverage with that provider. Your right to continue treatment for an ongoing special condition from the Non-Network provider will be valid for a transitional period of time as follows:

5 In general, you will have up to 90 days from the date of notice that such provider is no longer a Network provider, to continue treatment with your provider before benefits will end. For surgery, organ transplant, or inpatient care that was scheduled before you received notice that such provider is no longer a Network provider, or if you were on an established waiting list, the transitional period shall extend through the date of discharge. In addition, coverage with that provider shall include post discharge follow-up care related to the surgery, transplantation, or other inpatient care occurring within 90 days after the date of discharge. For pregnancy, if you have entered the second trimester of pregnancy on the date of notice that such provider is no longer a Network provider, you will have benefits with that provider through treatment of the pregnancy, which shall include 60 days of postpartum care. For a terminal illness, if the Covered Person is determined to be terminally ill at the time of a provider's termination as a Network provider, and the provider was treating the terminal illness before the date of the termination or enrollment in the new plan, the transitional period shall extend for the remainder of the Covered Person's life with respect to care directly related to the treatment of the terminal illness or its medical manifestations. When multiple Covered Services are performed, the Copayment, Coinsurance, and/or Deductible applicable to each Covered Service will apply. For example, a laboratory and x-ray service separately charged by an independent laboratory outside of the Physician s office has a separate Copayment, Coinsurance and/or Deductible in addition to the Physician s office Copayment, Coinsurance or Deductible. Premium rates and/or product forms included herein are subject to approval by regulators. If the rates or product forms offered herein are subsequently modified by regulators we will immediately advise you of the change in plan design and retroactively adjust premium in subsequent billings. This document is provided as a brief summary and is not intended to be a complete description of the benefit plan. After you become covered, you will be issued a Certificate of Coverage (COC) describing your coverage in greater detail. The COC will govern the exact terms, conditions, and scope of coverage. In the event of a conflict between this Schedule of Benefits and the COC, the language of the COC controls.

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