Coverage Overview. Preventive Care. For complete details, please call Aetna at

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1 Coverage Overview The following charts highlight our most commonly used services under the Progressive medical plans administered by Aetna. Please be aware that certain covered services are subject to specific limitations, requirements, and other provisions. For complete details, please call Aetna at Preventive Care Routine Physical Exams: Adults and Children > 7 exams in the first year of life > 3 exams from months > 3 exams from months > 1 exam every 12 months-age 3+ Immunizations/ Vaccinations Prenatal Visits Pap Smear Mammograms Female Contraceptive Methods (FDA-approved, generic and single-source only) Breastfeeding support, supplies and counseling Obesity screening and counseling Cancer Screenings > Colon/prostate > Cervical (pap) > Annual gynecological examination; clinical breast examination > HPV screening Endoscopy procedures > Colonoscopy > Sigmoidoscopy In-network: Free. Out-of-network: Visit the appendix at the end of this document and the Summary Plan Description on the Benefits site for more information on covered preventive services.

2 Emergency and Ambulance Services Emergencies: Urgent care and hospital emergency room Ambulance: Ambulance services must be medically necessary Occupational/Physical/Speech Therapies Occupational Therapy 60 combined physical, occupational and speech Physical Therapy therapy visits will be covered per year. Deductible and coinsurance apply. Speech Therapy Chiropractic visits 20 Chiropractic visits will be covered per year. Hospital Hospital (Facility) Charges Inpatient Charges Outpatient Surgery Charges Hospice Services Durable Medical Equipment Home Health Care 120 days will be covered per year. Deductible and coinsurance apply. Hearing and Vision Coverage Hearing Aids Hearing aids will not be covered by the plan, but Aetna offers a discount program of 30-60% off Hearing Exam For each covered person, limited to one hearing exam every 24 months. Covered at 100% in-network. Vision Exam For each covered person, limited to one vision exam per year. Covered at 100% for a VSP doctor or up to $35 for a non-vsp doctor. Our medical plans also cover a free eye exam within the Aetna network. Mental Health/Substance Abuse/Nervous Disorders Inpatient Charges Outpatient Charges

3 Resources for Living Employee Assistance Program (EAP) Worklife Services Free, confidential, 24-hour telephonic assistance for a variety of topics, including emotional concerns, substance abuse, parenting questions, and daily stress. All employees can take advantage of this benefit. Free services and support, including legal and financial consultations, child and elder care assistance, and convenience services. All employees can take advantage of this benefit. Prescription Drugs for the Standard Deductible Plan Your Cost for Retail Prescriptions Your Cost for Mail Order Prescriptions* Generic 10% ($10 Min/$40 Max) 10% ($20 Min/$80 Max) Preferred 20% ($20 Min/$65 Max) 20% ($40 Min/$130 Max) Non-preferred 35% ($35 Min/$90 Max) 35% ($70 Min/$180 Max) *Mandatory mail order is required for maintenance medications. Prescription Drugs for the High Deductible Plan The High Deductible Plan handles prescription drugs differently than the other plan options. Prescription drugs apply to the deductible in this medical plan. You will pay 100% of the discounted rate for prescription drugs until the deductible is met. Once the deductible is met, you will pay 20% coinsurance for any future covered prescriptions.

4 Dental Preventive Services Covered services include: Covered per calendar year: > 2 routine cleanings/exams > 1 bitewing x-ray > 1 fluoride treatment (for those under 16) Covered every three years: > 1 full-mouth x-ray > 1 sealant treatment on permanent molars only (for those under 16) As needed: X-rays, Periapical Minor Dental Work Covered work includes: > Fillings > Simple Extractions > Endodontics (excluding Molar Root Canals) > Periodontics (non-surgical) > Surgical Extractions (Tissue, Full, & Partial Bone*) > Gingivectomy Major Dental Work Covered work includes: > Inlays/Onlays > Crowns & Dentures > Bridgework > Occlusal Guards > TMJ Appliances and Diagnostics (Progressive Dental Plan only) > Crown Build Up > Crown and Bridge Repairs > Molar Root Canal Therapy > Osseous Surgery > General Anesthesia/Intravenous Sedation > Crown Lengthening > Implants (Progressive Dental Plan only) > Orthodontia Prosthetic replacements (e.g., crowns, inlays, implants, dentures) must have been in place for at least five years. Progressive Dental Plan In-network: 100% covered Out-of-network: 100% covered up to what is reasonable and customary in your area. You pay anything above what is reasonable and customary. Aetna DMO Dental Plan 100% covered (no coverage out-of-network) Progressive Dental Plan In-network: 20% coinsurance after deductible Out-of-network: 20% coinsurance (after deductible) up to what is reasonable and customary in your area. You pay anything above what is reasonable and customary. Aetna DMO Dental Plan 10% coinsurance (no coverage out-of-network) *(Partial/Full Bony Impactions are 40% coinsurance) Progressive Dental Plan In-network: 50% coinsurance after deductible Out-of-network: 50% coinsurance (after deductible) up to what is reasonable and customary in your area. You pay anything above what is reasonable and customary. Orthodontia: Separate $50 lifetime deductible and $2,500 lifetime maximum per person Aetna DMO Dental Plan 40% coinsurance (no coverage out-of-network) Orthodontia: No deductible or lifetime maximum. (Covers one phase of treatment. Does not cover braces again at a later age. Limited and Interceptive orthodontia not covered.)

5 Appendix More Information on Preventive Services Immunizations > DTaP-Hib Diphtheria, tetanus toxoids, acellular pertussis vaccine, and hemophilus influenza B vaccine > DTaP-IPV Diphtheria tetanus, acellular pertussis > DtaP-HepB-IPV Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and poliovirus vaccine > DTP-HIB- Diphtheria, tetanus toxoid, whole cell pertussis and hemophilia influenza B vaccine > TD- Tetanus-diphtheria > DT - Diphtheria, tetanus toxoid > Prevnar, Prevnar-Pneumococcal Conjugate > Influenza > DtaP = Deptheria-Tetanus-Acellular-Pertussis vaccine > TDAP- Deptheria-Tetanus-Toxoids-Acellular-Pertussis vaccine > DPT = Diphtheria-Tetanus-Pertussis vaccine > OPV = Oral Poliovirus Vaccine > IPV = Injectable Poliovirus vaccine > MMR = Measles-Mumps-Rubella vaccine > TriHIBit = Haemophilus influenza type > Hib and Hep B Hib - Hepatitis B and hemophilus influenza B vaccine > Hep A and Hep B Hepatitis A and B > Diphtheria > Tetanus Toxoid > HPV (Gardasil) - covered for girls and women 9 through 26 years of age. > Measles and Rubella > Measles > Mumps > Varicella > Rotavirus > Rubella > MMRV- Measles, mumps, rubella and varicella > Herpes Zoster covered for people over 60 years of age > Pneumococcal > Influenza (Flu Mist) > Meningococcal (Meningitis) vaccine Radiology > Mammograms: one annual > Osteoporosis screening: women 65 and over > Barium enema > EKG Laboratory > PSA prostate screening > CBC

6 Clinical Screenings > Fecal occult blood > Hemoglobinopathy screen > Metabolic panel (including newborn screening) > Thyroid studies > Chlamydia screening > Rubella serology > Cholesterol, lipid panel > Gonorrhea screening > RPR/VDRL > Hep B surface antigen > Hep C > HIV > HPV > Urinalysis > Lead screening > Skin test; Tuberculosis, intradermal > Venipuncture > Glucose; quantitative > Glucose; blood, reagent strip > Glucose; post glucose dose (includes glucose) > Glucose tolerance test (GTT) > Hemoglobin, glycosylated (A1C) > Anemia > Newborn metabolic screening panel > Blood pressure > Height & weight > Physical and mental status assessment, including: o Clinical breast exam o Clinical testicular exam o Complete skin exam > Newborn screening- PKU, sickle cell > Vision screening > Alcohol misuse > Depression screening Certain preventive services, such as immunizations, have specific restrictions not listed here. Please see the Summary Plan Description or contact Aetna for additional information.

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