Medical Benefits At-A-Glance

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1 Medical Benefits At-A-Glance Benefit Features Medical Benefit Summary UnitedHealthcare Plan of the River Valley, Inc. Network Deductible (Calendar Year) $2,850 self-only $5,650 self and family 4th Quarter Deductible Carryover Not applicable Maximum Out-of-Pocket (Calendar Year) $2,850 self-only $5,650 self and family Physician Medical Services Allergy Injections % after deductible Allergy Testing % after deductible Home Visits % after deductible Hospital - Inpatient Visits % after deductible Immunizations % coinsurance Injections % after deductible Maternity Care % after deductible Newborn Baby Care % after deductible Nursing Facility Visits % after deductible Routine Physical Exam $25 copayment/visit Surgical Services - Inpatient % after deductible Surgical Services - Outpatient % after deductible Surgical Services - Office % after deductible Vision & Hearing Screening $25 copayment/visit * Well Child Care $25 copayment/visit Urgent Care Center % after deductible Emergency Services Ambulance % after deductible Emergency Room Facility % after deductible Emergency Room Physician Care % after deductible Initial care only of a medical emergency is covered. Follow up care obtained in the emergency room is not covered. Facility Services Inpatient Hospital (Semi-Private Room) % after deductible Outpatient Facility or Surgi-Center Services % after deductible Nursing Facility (Limited to 100 days per calendar year) % after deductible Home Health Care (Must be approved in advance by UnitedHealthcare) % after deductible Medical Equipment Durable Medical Equipment Prosthetic Devices % after deductible Hearing Aid Devices % after deductible Maximum benefit of $5,000 per calendar year for Hearing Aid Devices. Outpatient Rehabilitative Therapy Physical Speech Occupational % after deductible Member is limited to 60 outpatient treatment days per calendar year.

2 Benefits Network Radiation Therapy & Chemotherapy Hospital (Outpatient) % after deductible Office % after deductible X-Ray and Laboratory Services Hospital (Outpatient) % after deductible As part of a preventive exam % coinsurance Office % after deductible As part of a preventive exam % coinsurance X-ray and laboratory services and procedures separately charged by an independent laboratory may require separate coinsurance and/or deductible, beyond the hospital coinsurance or physician office copayment/coinsurance. Mental Health Services Inpatient Facility % after deductible Inpatient Physician % after deductible Outpatient Facility % after deductible Substance Abuse Services Inpatient Facility % after deductible Inpatient Physician % after deductible Outpatient Facility % after deductible Benefit Maximum Plan Pays Lifetime Maximum Unlimited Definitions Copayment: The amount the member must pay for each medical service received, such as a physician office visit. Coinsurance: The percentage of cost that the member must pay for services received. Deductible: The amount the member must pay for health services, before the health plan begins to pay. Out-of-Pocket Maximum: The sum total amount of copayments, coinsurance and deductibles, as shown above for self-only or family and paid by the member, after which--for the remainder of the calendar year--the health plan will pay 100% of the Allowed Charge for that member s subsequent covered health care services. Note: Preventive Care refers to routine/physical examinations and services recommended by the U.S. Preventive Services Task Force. Exclusions Non-covered services include, but are not limited to: services not medically necessary experimental procedures or treatments personal or convenience items custodial care cosmetic services or surgery reversal of sterilization infertility services food or food supplements over-the-counter drugs dental, vision, hearing and prescription drugs (unless covered by supplemental benefit plan). Deductible does not apply. The amount for self-only coverage applies when the member alone is covered by this contract. The amount for family coverage applies when the member and eligible dependents are covered by this contract.

3 * Vision and hearing screening applies only for children 17 years of age and under to determine the need for vision and hearing correction. Routine eye examinations or refractions, including examinations for astigmatism, myopia, or hyperopia are not covered. 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 an evidence of coverage (Subscriber Agreement or Summary Plan Description) describing your coverage in greater detail. The evidence of coverage will govern the exact terms, conditions, and scope of coverage. In the event of a conflict between this Medical Benefits At-A-Glance, and the evidence of coverage, the language of the evidence of coverage controls.

4 Prescription Benefit Summary UnitedHealthcare Plan of the River Valley, Inc. Prescription Drug Benefits At-A-Glance Benefit Features Your coinsurance is determined by the tier to which the Prescription Drug List Management Committee has assigned the prescription drug product. All prescription drug products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. The applicable deductible as shown in the Medical Benefits At-A-Glance must be met before UnitedHealthcare begins to pay for prescription drug products covered under this Prescription Drug Benefits At-A-Glance. Prescription Drug Products Tier % after medical deductible Tier % after medical deductible Tier % after medical deductible Birth Control Tier % after medical deductible Tier % after medical deductible Tier % after medical deductible Definitions Application of Drug Coinsurance You will be responsible for the coinsurance after the applicable medical deductible has been met for each 90-day supply prescription fill or refill purchased at a retail pharmacy or by mail order. Drug coinsurance for prescription drug products do apply toward the medical maximum out-of-pocket expense, if applicable. Limitations Prescription quantity shall be limited to the amount ordered by the attending physician. Quantity per prescription fill or refill shall not exceed a 31-day supply or such other day supply as authorized by UnitedHealthcare. However, items on the 90-day supply list may be dispensed in quantities up to a maximum of 90-day supply through retail pharmacy or by mail order. UnitedHealthcare reserves the right to establish criteria and require prior authorization for certain prescription drug products. Specialty prescription drug products supply limits are as written by the provider, up to a consecutive 31-day supply of the specialty prescription drug product, unless adjusted based on the drug manufacturer s packaging size, or based on supply limits. Supply limits apply to specialty prescription drug products whether obtained at a retail pharmacy or through a mail order pharmacy. Some prescription drug products or pharmaceutical products for which benefits are described under this prescription drug rider or Subscriber Agreement or Summary Plan Description are subject to step therapy requirements. This means that in order to receive benefits for such prescription drug products or pharmaceutical products you are required to use a different prescription drug product(s) or pharmaceutical product(s) first. Also note that some prescription drug products require that you notify us in advance to determine whether the prescription drug product meets the definition of a covered service and is not experimental, investigational or unproven. UHC VA HY BS HDHP RX100% AHB

5 If you require certain prescription drug products, we may direct you to a designated pharmacy with whom we have an arrangement to provide those prescription drug products. If you are directed to a designated pharmacy and you choose not to obtain your prescription drug product from the designated pharmacy, you will be subject to the non-network benefit for that Prescription Drug Product. However, if the eligible non-network pharmacy (ENP) has entered into an agreement with UnitedHealthcare that is agrees to accept the same terms and conditions applicable to network pharmacies, including reimbursement at the rate applicable to network pharmacies, including any applicable coinsurance as payment in full, you may receive benefits on the same basis and at the same coinsurance as you would from a network pharmacy. Benefit Exclusions Non-covered items include, but are not limited to: medications available over the counter (OTC), unless (1) such OTC medication has been designated by UnitedHealthcare as eligible for coverage as if it were a prescription drug product, and (2) such OTC medication is obtained with a prescription from an attending physician compounded prescriptions growth hormones therapeutic or prosthetic devices drugs used for cosmetic purposes drugs used to enhance physical or mental performance treatment or supplies to promote smoking cessation dietary supplements, medications or treatment used for appetite suppression or weight loss, and nutritional formulas and supplements general vitamins medication for the treatment or enhancement of sexual performance or function drugs used for the treatment of infertility drugs used for experimental purposes. 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 an evidence of coverage (Subscriber Agreement or Summary Plan Description) describing your coverage in greater detail. The evidence of coverage will govern the exact terms, conditions, and scope of coverage. In the event of a conflict between this Prescription Drug Benefits At-A-Glance, and the evidence of coverage, the language of the evidence of coverage controls. UHC VA HY BS HDHP RX100% AHB

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