The MITRE Corporation Plan Benefit Summary Effective Date: 1/1/2015 Administered by Kaiser Permanente PLAN FEATURES You Pay and/or Maximums

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1 Benefit Type Plan Year Type Calendar Year Annual Medical Out of (for certain services) Employee Employee + 1 Family Annual Prescription Drug Out of Employee Employee + 1 Family The MITRE Corporation Plan Benefit Summary Effective Date: 1/1/2015 Administered by Kaiser Permanente PLAN FEATURES You Pay and/or Maximums $1,500 $1,500 $2,000 Each family Member has an individual Out-of- within the family Out-of-. The individual cannot contribute to the family Out-of- more than amount of a single Out-of-Pocket Maximum. Note the out-of-pocket limits are not integrated. Copayments: One copay per provider is charged per day. Visits: If multiple visits occur on the same day, each visit counts toward the applicable benefit limit. Benefit Type You Pay and/or Maximums Applies to Out-of- ROUTINE PREVENTIVE EXAMS Preventive Lab and X-ray screenings not specifically listed under the Preventive Screenings section are treated the same as nonpreventive Lab and Xray Services. See Preventive Services Listing, Screenings and Immunizations for a comprehensive list of Covered Services. Frequency and Age Limits managed by Network Provider except where noted. Wellness Exams Adults (Including Well Woman) Includes vision and hearing screenings. See Vision Exams for Refractions and Hearing Exams for audiologic testing. Wellness Exams Children Includes vision and hearing screenings. See Vision Exams for Refractions and Hearing Exams for audiologic testing. Preventive Screenings Immunizations (Preventive) Coverage applies to Adults and Children. OUTPATIENT VISITS (Office or Outpatient Facility) Primary Care cost share will be charged for Family Practice, General Internal Medicine and General Pediatrics specialties. Specialty Care cost share will be charged for visits with all other medical specialties. Frequency and Age Limits (if any) will be managed by KP Provider. Office Visits Primary care Specialty care $30 Allergy (Office Visit cost share based on ) Office Visit $30 Injection as part of an office visit (Includes serum) $30 Testing $30 Cardiac Rehab $30 Chemotherapy Services $30 Dialysis Services $30 Family Planning $30 Counseling, Implantable or Injectible Contraceptives Health Education Includes classes for Self Management of Asthma, Applicable Office Visit Cost Diabetes and Coronary Disease. Share based on. Hearing Exam (routine) Includes audiometry exam

2 OUTPATIENT VISITS (Office or Outpatient Facility) (cont'd) Hearing Aids (Adult) $0 N/A House Calls Applicable Office Visit Cost Share based on. No Infusion Services Requires skilled or medical administration. Injection only (materials and administration) Injections and Immunizations Non-routine including immunizations when not part of OV Copay for travel Nutrition Visits $30 Radiation Therapy $30 Respiratory/Pulmonary Therapy $30 Vision Exam (routine) Includes refraction exam HOSPITAL / SURGERY CHARGES Inpatient Hospital Includes room and board for private and semi-private rooms; ICU/CCU, Acute Rehab, Inpatient Professional Services, Medically Necessary Private Duty Nursing, Ancillary Services, Supplies. Per admission 0 Ambulance Emergency Ambulance Includes Ground and Air Ambulance Scheduled Ambulance: No Member Cost Share for hospital to hospital repatriation. Destinations covered when Medically Necessary: Home to hospital & return Home to skilled nursing facility Hospital to skilled nursing facility Skilled nursing facility to hospital Skilled nursing facility to home Home to doctor s office Hospital to hospital Skilled nursing facility to dialysis center and return Emergency Services Coverage for Accident and Illness. Copay waived if admitted. Urgent and After Hours Care Urgent Care and After Hours settings Outpatient Surgery Performed in Outpatient Hospital or Ambulatory Surgery Center. Bariatric Surgery Reconstructive Surgery: Includes procedures to improve function and change appearance for conditions due to disease, trauma, congenital/developmental anomalies, post-mastectomy (to produce symmetrical appearance only) and Medically Necessary surgery. $150 $100 Organ TransPlants Includes organ acquisition, diagnostic testing for donor and recipient Covered Transplants: Bone Marrow Heart/Lung Heart Kidney Liver Lung Pancreas Pancreas after Kidney alone Simultaneous Kidney & Pancreas Small Bowel Small Bowel and Liver

3 HOSPITAL / SURGERY CHARGES (cont'd) Benefit Maximum None N/A Travel and Lodging for Organ TransPlants Includes coverage for recipient, companion and donor for transportation, lodging and daily expenses. Daily expenses include incidental expenses such as meals and does not include personal expenses. Transportation Limits None N/A Lodging Limits None N/A Daily Expense Limits Reimbursement up to $50 per N/A day per person MATERNITY Routine Pre-Natal and Post-Partum Care Visit to confirm pregnancy $30 Pre-natal and first post-partum visit Hospital Inpatient Includes contracted Birthing Center Per admission 0 Maternity - Newborn Eligible Well Newborn Professional charges are covered under Well Newborn; Facility charges under the mother. Eligible Sick Newborn Professional and Facility charges are covered under the Sick Newborn DIAGNOSTIC TESTS & PROCEDURES Diagnostic Lab & Xray, Outpatient High Tech/Advanced Radiology - CT, MRI, Nuclear Medicine and PET, Outpatient $100 INFERTILITY SERVICES Includes further diagnosis and treatment of Infertility after initial diagnosis of infertility is made. Covered treatments include IVF, Artificial insemination, Surgery in addition to medically appropriate advanced reproductive services (e.g.gift and ZIFT). Lifetime Maximum (excludes prescription drugs) $25,000 Inpatient Hospital 0 Office Visit $30 Diagnostic Lab & Xray Outpatient Hospital or Ambulatory Surgery Center $100 MENTAL HEALTH & CHEMICAL DEPENDENCY SERVICES Mental Health - Inpatient Per admission Partial Hospitalization or Intensive Outpatient Per episode Mental Health Outpatient Individual Visit Cost Share Group Visit Cost Share 0 Chemical Dependency - Inpatient Detox covered under 0 Medical benefits. Per admission Chemical Dependency - Partial Hospitalization or Intensive Outpatient Per episode Chemical Dependency Outpatient Individual Visit Cost Share Group Visit Cost Share PHYSICAL, OCCUPATIONAL & SPEECH THERAPIES Outpatient Cost Share for therapies is applied on a 'per day' basis and visit counts on a 'per visit' basis. Physical Therapy $30 Occupational Therapy $30 Speech Therapy $30

4 SKILLED CARE Home Health Care Includes Nurse visits (2 hrs), Aide visits (4 hours), therapy visits and supplies. Limited to 40 visits per calendar year Home Infusion Requires skilled or medical administration. Includes Infusions and Supplies Hospice Skilled Nursing Facility Per admission Days per calendar year OTHER SERVICES Acupuncture $30 combined with Chiropractic Chiropractic Care $30 combined with Acupuncture Dental Care Includes Preparation of the Jaw for Radiation Treatment, where Dental Anesthesia under certain circumstances, medical and surgical Services are received and. treatment of TMJ. Durable Medical Equipment Breast Feeding Pump Prosthetics and Orthotics Special Oral Foods Amino Acid Modified Products and PKU Fitness Reimbursement $150 per calendar year OUTPATIENT PRESCRIPTION DRUGS Outpatient Prescription Drugs Retail (must be obtained from KP medical center pharmacies unless otherwise specified) - Generic - Copay at Network Pharmacy CA $10/30 days - Copay at Network Pharmacy CO $5/30 days - Copay at Network Pharmacy MAS $10/30 days - Copay at Community/Network Pharmacy (MAS only) /30 days - Formulary Brand - Copay at Network Pharmacy CA /30 days - Copay at Network Pharmacy CO $15/30 days - Copay at Network Pharmacy MAS /30 days - Copay at Community/Network Pharmacy (MAS only) $40/30 days - Non-Formulary Brand - Copay at Network Pharmacy CA $35/30 days - Copay at Network Pharmacy CO $30/30 days - Copay at Network Pharmacy MAS $35/30 days - Copay at Community/Network Pharmacy (MAS only) $55/30 days Mail Order Drugs - Generic - Copay CA: /up to100 days - Copay CO: $10/up to 90 days $10/up to 30 days - Formulary Brand - Copay CA: $40/up to100 days - Copay CO $30/up to 90 days /up to 30 days

5 OUTPATIENT PRESCRIPTION DRUGS (cont'd) - Non-Formulary Brand - Copay CA: $35/up to 30 days 2x Copay 31 to 100 days - Copay CO $60/up to 90 days $35/up to 30 days Blood and Blood Products Diabetic Coverage - Oral Medications and Insulin Generic/Formulary Brand - Diabetic testing supplies (meters, test strips) Generic/Formulary Brand - Diabetic administration devices (syringes) Generic/Formulary Brand Smoking Cessation 50% Weight Loss 50% ACA Mandated Drugs Contraceptive Devices (diaphragms, cervical caps, etc.) and Drugs Emergency Contraception

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