At Issue Comparison-Health Insurance Printed: 12/12/05. Unity's doctors. different doctor/clinic. Referral with Dean's approval only.

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1 Member's choice; each family Member's choice; subject to All family members must use All family members must use member may receive care from deductible and co-insurance. Dean's doctors. Unity's doctors. different doctor/clinic. Selection of M.D./Clinic/Healthcare Provider Referral May self-refer to anyone in WPS Member's choice; subject to statewide network or via deductible and co-insurance. nationwide Beech Street Network; same deductible; no co-pay for self referring. Referral with Dean's approval only. All family members must use GHC's doctors. Referral with Unity approval only. Referral with GHC approval only. Coverage Out of Madison Area Member's choice; coverage same Member's choice; coverage same as using Madison area doctor who as using Madison area doctor who is in WPS' statewide network or, if is in WPS' statewide network or if out of state, using a Beech Street out of state, using a Beech Street provider (see above). provider (see above). Emergency care only. Emergency care only Emergency care only. Medical Reimbursement Policy year deductible is $300 single, $600 family. Prescription drug and mental/nervous, alcohol/drug expenses due are not counted toward deductible or out of pocket maximum. All out of network covered expenses are subject to a 20% coinsurance after satisfying the $300 single or $600 family annual deductible. Maximum out of pocket expenses due to deductibles and coinsurance are $800 single and $1600 family. Prescription drug and mental/nervous, alcohol/drug expenses due are not counted toward deductible or out of pocket maximum. As long as care is provided through DEAN primary care provider or referral there are no deductibles or co-payments. No limits in days or dollars of coverage, except where noted. No claim forms. As long as care is provided through UNITY primary care provider or participating specialist there are no deductibles or copayments. No limits in days or dollars of coverage, except where noted. No claim forms As long as care is provided through GHC primary care provider or referral there are no deductibles or co-payments. No limits in days or dollars of coverage, except where noted. No claim forms. Hospitalization Subject to deductible. Subject to deductible and Semi-private room and Semi-private room and miscellaneous hospital expense for miscellaneous hospital expense for 365 days per confinement are 365 days per confinement are covered. covered. $2,000,000 lifetime maximum Outpatient : Covered in Full Hospice: Limited to 6 months per member per lifetime 3 business day prior preadmission certification required. 3 business day prior preadmission certification required. Call DEAN at within 48 hours of any out-of-area emergency hospital admission. Call Unity at within 72 hours of any out-of area emergency hospital admission. Call GHC at Ext within 48 hours of any out-ofarea emergency hospital admission. Page 1

2 Hospitalization (cont'd) Any out of area follow-up care is not covered. Any follow-up care must be preauthorized to be covered and will be covered at 50% of reasonable and customary Surgical-Medical Care Subject to deductible. Subject to deductible and Maternity Subject to deductible. Subject to deductible and Physician Visits in Hospital Subject to deductible. Subject to deductible and X-ray and Lab Test Subject to deductible. Subject to deductible and Radiation Subject to deductible. Subject to deductible and Therapy/Chemotherapy Emergency Care Subject to deductible. Subject to deductible and Covered in full 100% of usual and customary charges. Call DEAN at within 48 hours of any out-of-area care. Follow up care out of area is covered at 50% of usual and customary with pre-authorization. $25 emergency room copayment. Copayment waived upon admission to hospital. Call Unity at within 72hours of any out of area Emergency care Out-of-area medical care that is medically necessary, non-urgent, non-emergency or follow-up medical care will be covered at 50% of eligible charges. Out-ofarea care must receive prior authorization by GHC. Physicians Office Visits Subject to deductible. Subject to deductible and Regular Examinations Subject to deductible. Subject to deductible and Pediatric Care Subject to deductible. Subject to deductible and Covered in full to age 6 Page 2

3 Immunizations Subject to deductible. Subject to deductible and Childhood immunization covered through age 17. Travel immunizations covered only when travel is scheduled. Travel Immunizations: Travel Immunizations: Contact GHC at directly for restrictions and co-payments pertaining to travel related drugs. Injections Subject to deductible. Subject to deductible and Psychiatric Care Outpatient Outpatient: 100% of first $1,000 Outpatient: 100% of first $1,000 Outpatient: 20 visits per benefit per policy year, subject to and in conjunction with the first 10-hour lifetime maximum benefit limit. 90% of the next $1,000 then 75% per policy year, subject to and in conjunction with the first 10-hour lifetime maximum benefit limit. 90% of the next $1,000 then 75% period. of the remaining charges thereafter of the remaining charges thereafter per policy year. per policy year. Contact Unity at with questions. Covered when provided by a participating provider. Some may require prior authorization. Combined benefits of $7,000 for Both Psychiatric and Alcohol and Drug Abuse Outpatient: 100% of coverage up to an insured benefits of $1,800 per cotract year. Thereafter, for Psychological disorders only, this benefit will be limited to 100% of 1 additional day of outpatient services per member per contract year. Outpatient: Maximum 20 visits per calendar year. Includes all state mandates. Inpatient Inpatient: 100% of semi-private room and miscellaneous hospital expenses for 365 days per confinement less any state mandated benefit. Inpatient: 90% of semi-private room and miscellaneous hospital expenses for 365 days per confinement less any state mandated benefit. Inpatient: 10 days per benefit period Inpatient: Limited to the lesser of 100% coverage up to 30 days or an insured benefit of $6,300 per contract year. Thereafter for Psychological disorders only, this benefit will be limited to 100% of 1 additional day of inpatient services Inpatient: 30 days per calendar year covered at 100%. Limited to $6,300 if out-of-area emergency. Page 3

4 Psychiatric Care (cont'd) - Transitional Care Transitional Care: 100% of coverage up to an insured benefits of $2,700 per cotract year. Thereafter, for Psychological disorders only, this benefit will be limited to 100% of 1 additional day of transitional services per member per contract year. Transitional Care: 15 days per benefit period Alcohol & Drug Abuse Outpatient Inpatient Outpatient: This is a combined benefit with psychiatric care. Inpatient: 100% of charges up to the lesser of the charges for the first 30 days of the confinement or $7000 in charges for such services each policy year. Outpatient: This is a combined benefit with psychiatric care. Outpatient: This is a combined benefit with psychiatric care. Inpatient: 100% of charges up to Inpatient: This is a combined the lesser of the charges for the benefit with psychiatric care. first 30 days of the confinement or $7000 in charges for such services each policy year. This is a combined benefit with psychiatric care for inpatient, outpatient and transitional services to a maximum of $7,000 per member per contract year. Outpatient: Maximum of $1,800 in billed services per calendar year. Inpatient: Lesser of 30 days per calendar year covered at 100% or $6300 per calendar year. Transitional: 90% of the first Transitional: 90% of the first Transitional: Up to 15 Full day $3000 in charges each policy year, $3000 in charges each policy year, visits per benefit period. then 75% of charges thereafter. Any additional benefits payable will not apply to the maximum stated below. then 75% of charges thereafter. Any additional benefits payable will not apply to the maximum stated below. Transitional: Maximum combined benefit of $6300 per calendar year. Cardiac Rehabilitation Chiropractic Coverage Total benefits shall not exceed $8000 per member. Subject to deductible. Maximum of 48 supervised sessions for specified conditions. Total benefits shall not exceed $8000 per member. Subject to deductible and Maximum of 48 supervised sessions for specified conditions. Must be started within 21 days of Must be started within 21 days of discharge. discharge. Subject to deductible. As any Subject to deductible and other covered professional service. As any other covered professional service. Covered at 100% if provided in an approved outpatient facility Covered in full at DEAN contracted providers. Limited to 36 sessions in a 12- month period following hospitalization. Must be approved by GHC. Covered in full at UNITY Covered in full at GHC contracted contracted providers. Maintenance providers. care is not covered. Page 4

5 Involuntary Infertility 100% of charges limited to infertility diagnostic service only. 100% of charges limited to infertility diagnostic service only. 50% copayment of first $4,000. Covered within limits of the policy. Please refer to certificate Covered within the limits of the policy. Please refer to certificate. Coverage for Infertility Services will be limited to 50% of Covered Expenses up to a Lifetime Benefits Maximum of each member of $30,000, with a maximum payment by GHC of $15,000. Includes diagnosis and treatment??????? Acupuncture Subject to deductible. Preauthorization is recommended after 17 visits. Subject to deductible and Preauthorization is recommended after 17 visits. Not covered. Not covered Complementary medicine services include Acupuncture, Massage Therapy, Stress Reduction, Yoga, Tai Chi, Movement Therapy, Lifestyle Change Classes, and more as outlined in the Member Certificate. Complementary medicine professional services, when provided by GHC. Complementary Medicine practicioner at a GHC owned and operated facility will be covered at 50% of the first $500 in eligible charges, with a maximum payment by GHC of $250 per calendar year. Page 5

6 Prescription Drugs Legend drugs $6 co-pay prescription or refill for generic. Preferred brand name drugs $12 co-pay prescription or refill. All other brand name drugs $25 copay prescription or refill. $250 annual maximum for brand name drugs on the third tier for which there is not a generic or 2 nd tier drug available. Legend drugs $6 co-pay prescription or refill for generic. Preferred brand name drugs $12 co-pay prescription or refill. All other brand name drugs $25 copay prescription or refill. $250 annual maximum for brand name drugs on the third tier for which there is not a generic or 2 nd tier drug available. $6 Formulary $6 Generic copay per prescription or re-fill. Legend drugs $6 co-pay prescription or refill for generic. Brand name drugs $12 prescription or refill. 1 co-pay for each 30 day supply. Prescriptions must be purchased at GHC designated pharmacies. Includes oral contraceptives. Most prescriptions limited to a 30-day supply. Oral contraceptives available in a 90-day supply. Brand name prescription drug buy-option: If a member requests a brand name drug when its generic is available the member will be responsible for the difference in cost between the brand name and generic drugs, as well as the applicable brand name co-payment. 90 day supply. 90 day supply. $12 Non Formulary $12 Brand copay per prescription or re-fill. Insulin prescriptions are limited to a 30 day supply per prescription. Oral contraceptives are covered. Oral contraceptives are covered. Includes Insulin and Disposable Diabetic supplies $24 Non formulary Brand copay per prescription or re-fill. Insulin supplies are covered with no copay. Insulin supplies are covered with no copay. Prescriptions must be obtained at a participating Unity pharmacy. Includes oral contraceptive. 1 copay for each 30 day supply 30 day supply limit per prescription for most. Mailorder is available for some maintenance drugs. Member must contact UW Pharmacy for program specifics. 90 day supply for2 1/2 copayments if approved. Mail order: You may receive a 90 day supply for a Dean Approved Maintenance drug at a 2 month copay Mail order is expected to be available as of 7/1/05 Page 6