Services and supplies required by Health Care Reform Age and frequency guidelines apply to covered preventive care Not subject to deductible if PPO

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1 Page 1 of 5 Individual Deductible Calendar year $400 COMBINED Individual / Family OOP Calendar year $4,800 Individual $12,700 per family UNLIMITED Annual Maximum July 1 st to June 30 th UNLIMITED UNLIMITED Inpatient Hospital Failure to preauthorize will result in a $300 deduction of benefits otherwise payable for covered expenses incurred. Further, the Eligible individual will be responsible for the hospital room and board charges that were not preauthorized $500 co pay if Non PPO Outpatient Surgery No preauthorization required Office Visit $20 copay per visit Preventive Care/ Screening / Immunizations Services and supplies required by Health Care Reform Age and frequency guidelines apply to covered preventive care Emergency Room $50 co pay Deductible waived if admitted to hospital Life threatening emergency services performed in an out of network emergency room accumulate to meet the in network outof- pocket. R&C (if True emergency) Urgent Care Facility $20 copay per visit Inpatient Surgery Anesthesia Chemotherapy Foot Orthotics One pair every 4 years for adults, one pair every 6 months for children to age 19 when replacement is due to growth when prescribed by a doctor

2 X-Ray and Lab Page 2 of 5 Contact American Health Group for Maternity Program Preauthorization required only if hospital stay is more than 48 hours for vaginal delivery or 96 hours for C-section Maternity Prenatal and Postnatal Office Visits for all females* *Codes for prenatal visits should be filed separate from global maternity to ensure member coverage at 100% with no cost sharing Ultrasound Diagnostic test ONLY Delivery expenses for dependent child Not Covered Inpatient Newborns Circumcision covered if performed during initial confinement Supplemental Accident Benefit Limited to $1,000 per Individual, per calendar year. Treatment must take place within 3 months from the date the accident occurred. Not subject to deductible Does not accumulate towards the annual Out of Pocket maximum 100%of up to $1,000 Max R&C up to $1,000 Max Mammogram Ages 35 thru 39: one base line screening Ages 40 and older: one each calendar year Family history Birth Control for Females IUD, Injectables, Implants Oral (contraception) thru pharmacy. No co pay. Female Sterilization Sterilization Male Sterilization

3 Page 3 of 5 Routine Colonoscopy Age 50 and older, once every 10 years Chiropractic (Spinal Manipulation) 10 visits and one x-ray per calendar year Home Health Care Limited to 40 days per calendar year to include: Part time intermittent skilled nursing and supplies Part time intermittent services of a home health aid Skilled Nursing Facility Limited to 60 days per calendar year Outpatient Rehabilitation Services (Physical / Occupational / Speech Therapy) 50 visits per person per calendar year for any combination of physical, occupational and or speech therapy Inpatient Rehabilitation Services (Physical / Occupational / Speech Therapy) $500 co pay if Non PPO Hospice Life expectancy 6 months or less Includes bereavement counseling TMJ Expenses for diagnosis, treatment or prevention not covered Dental appliance for TMJ covered under the dental plan 0% 0%

4 Page 4 of 5 Submit LOMN, purchase price and HCPC codes with claim Durable Medical Equipment Breast Pump- For the first 12 months Rental (Up to purchase) or purchase for standard manual or standard electric, plus necessary supplies Repair, adjustment or servicing Organ / Donor Transplants Call Fund Office for benefits Smoking Cessation Products Includes over the counter and prescription smoking / tobacco cessation drugs Requires a Provider prescription for all products Not subject to deductible if purchased at In-network Retail store Dietician / Nutrition Counseling 3 visits, per person, per calendar year Provider must be a registered dietician $20 copay per visit Hearing Exam If medically necessary Hearing Aids / Cochlear Implants Cochlear Implants / Hearing Aids payable up to $700 per ear during any 48 month period when performed and prescribed by a licensed clinical audiologist up to the Max benefit R&C up to the Max benefit Sleep Study Call Fund Office for benefits Diabetes Education 5 visits per person per lifetime Must be ordered by a Physician In / Outpatient Mental Nervous/ Substance Abuse Contact Blomquist Hale for benefits

5 Page 5 of 5 NOT COVERED Not limited to: work related, cosmetic, obesity/morbid obesity, reversal of sterilization, custodial care in a facility, jaw repositioning procedures, growth hormones, educational training (except as noted in the schedule of benefits), elective abortions, dependent child delivery charges, acupuncture, infertility, treatments not medically necessary, TMJ, expenses incurred for dental services except for accidental injury to sound natural teeth under the Supplemental Accident benefit. NOTES ALL CLAIMS MUST HAVE THE PLAN MEMBERS GROUP # (S006) ON THE CLAIM FORM OR IT MAY GET REJECTED. (HCFA FORMS- BOX 11 UB FORMS- BOX 62) FILING A CLAIM FILING LIMIT- 90 days from incurred date and in no event later than 1 year from incurred date. APPEAL TIME FRAME- 180 days from the day the claim was processed. *********ELIGIBILITY IS BASED ON A MONTH BY MONTH BASIS********* CONTACT INFORMATION Mail claims to: JAS, Inc., 4885 South 900 East, Suite #202, Salt Lake City, Utah Fund Office-Customer Service (801) or toll free (800) Fax (801) Medical Preauthorization Company: American Health Group (800) ~ Fax (480) *Blomquist Hale (BHC) (800) ALL Mental Nervous & Chemical Dependency Sleep Study and Pre-certification Company: Depot Drug- (800) Prescription Program- CVS Caremark- Retail (888) / Specialty Pharmacy (800) DISCLAIMER This is not a guarantee of Benefits. This is a general summary of the benefits available under this plan and not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant s eligibility and benefits are based upon the information currently available to us. Both are subject to change without notice. All benefits are subject to pre-existing condition limitations as specified in the plan. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier if other coverage is involved.

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