Health Plan Comparison Chart

of 6 Health Plan Comparison Chart Background Information Outpatient Services Inpatient Services Prescription Drug Coverage Other Services The data provided in the chart below is for the 2015 plan year. Compare Again to choose different Health plans and/or comparison points. Return to the Medical page. The Health Plan Comparison Chart is provided for informational purposes. As a result of health care reform, there are developing changes that may impact plan final governmental regulatory clarifications on these provisions which may result in changes to certain plan benefits. In the event of a conflict between the Healt Comparison Chart and plan terms, plan terms will govern. Background Information Plan Facts Product name on web site PPO (Participating Provider Option) PPO (Participating Provider Option) Plan description Point of Service Preferred Provider Organization Member services 1-800-621-7336 1-800-621-7336 Web site bcbsil.com/att bcbsil.com/att Group ID Cost Sharing Deductible: Individual/Family Annual Out-of-pocket maximum: Individual/Family 00097- For AT&T Benefits Center Use Only $500 Individual; $1,000 Family; Non- $1,300 Individual; $2,600 Family; $2,000 Individual; $4,000 Family; excludes ; combined with Non- $6,000 Individual; $12,000 Family; excludes ; combined with 00105- For AT&T Benefits Center Use Only $500 Individual; $1,000 Family; Non- $1,300 Individual; $2,600 Family; $2,000 Individual; $4,000 Family; excludes ; combined with Non- $6,000 Individual; $12,000 Family; excludes ; combined with Outpatient Services Primary Care Primary doctor office visit Non- Non-

of 6 Specialist office visit Non- Non- Outpatient Care Outpatient surgery Non- ; preauthorization ; preauthorization Non- 60% covered after ; subject to Reasonable and ; preauthorization ; refer to SPD for details Outpatient laboratory services 90% covered after Non- 60% covered after ; subject to Reasonable and Non- Outpatient physical therapy ; refer to SPD for details Non- ; refer to SPD for details Non- Outpatient X-ray 90% covered after Non- 60% covered after ; subject to Reasonable and Non- Family Planning/Maternity Care Office visit: Pre/postnatal Non- Non- In-hospital delivery services Fertility services Non- ; preauthorization ; limited to $20,000 per lifetime;, Non- and ONA combined; includes Rx preauthorization Non- ; limited to $20,000/lifetime; /Non- /ONA combined; incl Rx; preauth ; preauthorization Non- ; preauthorization Non-

of 6 Preventive Care Annual physical exam Well-woman exam (includes pap) Mammogram Pediatric exams Non- Non- Non- Non- Non- Non- Non- Non- Inpatient Services Inpatient Room and Board Hospital copay or coinsurance Hospital semi-private room Non-, subject to Reasonable and Non- ; preauthorization ; preauthorization Non- ; preauthorization 90% of Allowable Charges covered; after ; preauthorization Non- ; preauthorization Inpatient Care Inpatient lab and X-ray Inpatient physician and surgeon services Non-, subject to Reasonable and Non- ; preauthorization Non- Non- Emergency Care Emergency room Non- For true emergencies, refer to provisions; non-emergencies: 60% of Non- For true emergencies: refer to provisions; non-emergencies: 60% of

of 6 Urgent care clinic visit Ambulance services Non- ; Non- - 60% of Non- ; Non- - 60% of Prescription Drug Coverage General Annual prescription Non- Non- Prescription drug Web site caremark.com caremark.com Prescription drug member services phone number 1-800-378-8851 1-800-378-8851 Prescription drug vendor CVS Caremark CVS Caremark Annual prescription out-ofpocket maximum Retail $900 Individual; $1,800 Family; copays apply Non- $900 Individual; $1,800 Family; copays apply Non- Retail generic Retail formulary brand Retail nonformulary brand $10 copay; up to 30 day supply; two fill max on maintenance drug, mandatory mail order Non- 25% copay of the Non- cost of the drug or the Generic $30 copay; up to 30 day supply; Non- 25% copay of the Non- cost of the drug or the Preferred $60 copay; up to 30 day supply; Non- 25% copay of the Non- cost of the drug or the Nonpreferred $10 copay; up to 30 day supply; two fill max on maintenance drug, mandatory mail order Non- 25% copay of the Non- cost of the drug or the Generic $30 copay; up to 30 day supply; Non- 25% copay of the Non- cost of the drug or the Preferred $60 copay; up to 30 day supply; Non- 25% copay of the Non- cost of the drug or the Nonpreferred

of 6 Mail Order Mail order generic $20 copay; up to 90 day supply $20 copay; up to 90 day supply Mail order formulary brand Mail order nonformulary brand $60 copay; up to 90 day supply; if $120 copay; up to 90 day supply; if $60 copay; up to 90 day supply; if $120 copay; up to 90 day supply; if Other Services Mental Health Mental Health and Substance Abuse Vendor Mental Health and Substance Abuse Web Site ValueOptions achievesolutions.net/att ValueOptions achievesolutions.net/att Mental Health and Substance Abuse Phone Number 1-800-554-6701 1-800-554-6701 Mental Health: Outpatient coverage ; and Out-of- Non- ; combined with and Rx ; and Out-of- Non- ; combined with and Rx Mental Health: Inpatient coverage ; and Out-of- Non- ; and Out-of- ; and Out-of- Non- ; and Out-of- Substance Abuse Detox: Outpatient coverage Detox: Inpatient coverage ; and Out-of- Non- ; combined with and Rx ; and Out-of- Non- ; and Out-of- ; and Out-of- Non- ; combined with and Rx 90% covered after ; and Out-of-Pocket Maximum combined with Non- ; and Out-of-

of 6 Rehab: Outpatient coverage ; and Out-of- Non- ; combined with and Rx ; and Out-of- Non- ; combined with and Rx Rehab: Inpatient coverage ; and Out-of- Non- ; and Out-of- ; and Out-of- Non- ; and Out-of- Alternative Care Chiropractic ; refer to SPD for details Non- ; refer to SPD for details Non- ; refer to SPD for details Other Noncustodial home health care Non- ; preauthorization ; refer to SPD for details ; preauthorization Non- ; preauthorization The comparison charts are compiled using information that applies to a large number of health plan users and is commonly reported by the health plans. Depen chart type, such as charts for dental plans, certain information and/or sections won't appear because the necessary data isn't available. If you have questions a that isn't covered in the charts, contact the plan's member services department for additional information. Also, keep in mind that the information on access an care is provided by the health plans. Neither AT&T Inc. nor Hewitt Associates is responsible for the accuracy of this information. If there is a discrepancy betwee information displayed on these charts and the official plan documents, the official plan documents will control. AT&T Inc. reserves the right to amend, suspend, the plan(s) or program(s) at any time. 2005-14 Aon plc