Benefit Plan Summaries. For groups with 2 to 50 employees. Effective January 1, 2016

Benefit Plan Summaries For groups with 2 to 50 employees Effective January 1, 2016

Network options UPMC Health Plan offers the following network options for our 2-100 market portfolio. Erie Warren McKean Susquehanna Tioga Bradford Potter Crawford Wayne Forest Wyoming Elk Cameron Sullivan Lackawanna Venango Lycoming Pike Mercer Clinton Clarion Luzerne Jefferson Lawrence Columbia Monroe Clearfield Montour Butler Centre Union Carbon Armstrong Northumberland Beaver Snyder Northampton Indiana Mifflin Schuylkill Juniata Lehigh Dauphin Allegheny Cambria Blair Perry Berks Bucks Westmoreland Lebanon Huntingdon Washington Montgomery Cumberland Lancaster Bedford Chester Somerset Philadelphia Fayette York Delaware Greene Fulton Franklin Adams Standard Network Only employer groups domiciled within the 28 counties in our service area are able to purchase this plan. Your employees will be covered for services when they seek care from participating providers within the UPMC Standard Network. These include all UPMC-owned facilities and providers in addition to other network facilities.

Erie Warren McKean Susquehanna Tioga Bradford Potter Crawford Wayne Forest Wyoming Elk Cameron Sullivan Lackawanna Venango Lycoming Pike Mercer Clinton Clarion Luzerne Jefferson Lawrence Columbia Monroe Clearfield Montour Butler Union Centre Armstrong Carbon Northumberland Beaver Snyder Northampton Indiana Mifflin Schuylkill Cambria Juniata Lehigh Dauphin Allegheny Blair Perry Berks Lebanon Bucks Westmoreland Huntingdon Montgomery Cumberland Washington Lancaster Bedford Fulton Chester Somerset Philadelphia Fayette Franklin York Delaware Greene Adams Premium Network Only employer groups domiciled within the 29 counties in our service area are able to purchase this plan. Your employees will be covered for services when they seek care from participating providers within the UPMC Premium Network. These include all UPMC-owned facilities and providers in addition to other network facilities.

Medical plan descriptions

UPMC Small Business Advantage UPMC Small Business Advantage includes plans that use our Standard and Premium networks. All plans cover preventive care at 100 percent. UPMC Consumer Advantage UPMC Consumer Advantage qualifies your employees for a health savings account (HSA). An HSA is an account for current and future health care expenses. The employer may contribute to it along with the employee, but the employee owns the HSA, keeps it year after year as it grows, and can take it along when he or she retires or leaves the company. All plans cover preventive care at 100 percent. UPMC HealthyU HealthyU is an innovative plan that rewards your employees for making healthy choices. By completing healthy activities, your employees earn reward dollars in a health incentive account (HIA) that helps to pay for their health care expenses. HealthyU recommends healthy activities that are uniquely customized to the individual, each with a reward dollar value to help them focus on what s most important to understanding and improving their own health. Every time they complete a recommended activity, UPMC Health Plan deposits those reward dollars into their HIA. The reward dollars they earn can help pay for out-of-pocket medical expenses, such as deductible, coinsurance, and pharmacy copayments. All plans cover preventive care at 100 percent. UPMC Inside Advantage UPMC Inside Advantage is a tiered network plan that provides your employees with the same type of coverage as other UPMC Health Plan offerings but with lower out-of-pocket costs when they receive care at these select facilities: Grove City Medical Center, Kane Community Hospital, Warren General Hospital, UPMC Hamot, UPMC Horizon, UPMC Northwest, and all other UPMC-owned facilities. Employers in these counties are eligible: Clarion, Crawford, Elk, Erie, Forest, McKean, Mercer, Potter, Venango, and Warren. All plans cover preventive care at 100 percent. Here are descriptions of each plan type: EPO With UPMC Health Plan s EPO (Exclusive Provider Organization) health benefit plan, your employees must receive care from network physicians and facilities (except in the case of emergency services). Preventive care is always covered at 100 percent. And your employees do not need a referral to see a specialist. PPO UPMC Health Plan s PPO (Preferred Provider Organization) health benefit plan allows your employees to go out of the network to receive care; however, your employees out-of-pocket expense may be lower if they receive care from a network physician or facility. Preventive care is always covered at 100 percent. And your employees do not need a referral to see a specialist. HMO With UPMC Health Plan s HMO (Health Maintenance Organization) health benefit plan, your employees must receive care from network physicians and facilities (except in the case of emergency services). Your employees must select a PCP who will help coordinate their care. A PCP referral is required for most specialty care. Preventive care is always covered at 100 percent.

Plan details All plans are SHOP Marketplace-eligible. This document is meant to assist in comparing benefit plans. It is not a contract. If differences exist between this summary and a group s contract or a member s Certificate of Coverage, the contract or Certificate of Coverage will prevail. UPMC Small Business Advantage Network: Standard Plan Name Deductible (I/F) Out-of-Pocket Maximum (I/F) Coinsurance PCP Visit E-visit Specialist Office Visit Urgent Care Emergency Department Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.) Lab and Other Services Silver HMO $3,000 $10/$25 $3,000/ $6,000 $6,850/ $13,700 0% $10 $5 $40 $40 $175 1 $300 2 $300 $40 $40 Gold HMO $1,000 $10/$25 $1,000/ $2,000 $3,750/ $7,500 0% $10 $5 $25 $25 $175 1 $0 2 $0 2 $30 $30 Platinum HMO $20/$40 $0/$0 $1,500/ $3,000 0% $20 $10 $40 $40 $175 1 $500 $150 $30 $30 1 Waived if admitted 2 After deductible

UPMC Inside Advantage Network: Premium Plan Name Deductible (I/F) Out-of-Pocket Maximum (I/F) Coinsurance PCP Visit E-visit Specialist Office Visit Urgent Care Emergency Department Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.) Lab and Other Services Silver PPO $5,000 $20/$40 Level 1 $5,000/ $10,000 Level 2 $6,350/ $12,700 Non-Participating Provider $6,850/ $13,700 Silver PPO $3,000 $20/$40 Level 1 $3,000/ $6,000 Level 2 $6,000/ $12,000 Non-Participating Provider $6,850/ $13,700 Gold PPO $1,250 $20/$40 Level 1 $1,250/ $2,500 Level 2 $2,500/ $5,000 Non-Participating Provider $5,000/ $10,000 Platinum PPO $250 $20/$40 Level 1 $250/ $500 Level 2 $500/ $1,000 Non-Participating Provider 1 Waived if admitted 2 After deductible $6,000/ $12,000 $6,350/ $12,700 $6,350/ $12,700 $10,000/ $20,000 $6,850/ $13,700 $6,850/ $13,700 $10,000/ $20,000 $3,000/ $6,000 $3,000/ $6,000 $10,000/ $20,000 $1,000/ $2,000 $2,000/ $4,000 $10,000/ $20,000 0% $20 $10 $40 $40 $100 1 $0 2 $0 2 $30 $30 35% $20 $10 $40 $40 $100 1 35% 2 35% 2 $30 $30 40% 40% 2 40% 2 40% 2 40% 2 $100 1 40% 2 40% 2 40% 2 40% 2 0% $20 $10 $40 $40 $175 1 $0 2 $0 2 $30 $30 35% $20 $10 $40 $40 $175 1 35% 2 35% 2 $30 $30 40% 40% 2 40% 2 40% 2 40% 2 $175 1 40% 2 40% 2 40% 2 40% 2 0% $20 $10 $40 $40 $100 1 $0 2 $0 2 $30 $30 35% $20 $10 $40 $40 $100 1 35% 2 35% 2 $30 $30 40% 40% 2 40% 2 40% 2 40% 2 $100 1 40% 2 40% 2 40% 2 40% 2 0% $20 $10 $40 $40 $175 1 $0 2 $0 2 $30 $30 35% $20 $10 $40 $40 $175 1 35% 2 35% 2 $30 $30 40% 40% 2 40% 2 40% 2 40% 2 $175 1 40% 2 40% 2 40% 2 40% 2

Network: Premium Plan Name Deductible (I/F) Out-of-Pocket Maximum (I/F) Coinsurance PCP Visit E-visit Specialist Office Visit Urgent Care Emergency Department Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.) Lab and Other Services Silver EPO $5,000 $10/$40 $5,000/ $10,000 $6,850/ $13,700 0% $10 $5 $40 $40 $175 1 $300 2 $300 2 $40 $40 Silver EPO $3,000 $10/$40 $3,000/ $6,000 $6,850/ $13,700 0% $10 $5 $40 $40 $175 1 $300 2 $300 2 $40 $40 Silver EPO $2,500 $20/$40 $2,500/ $5,000 $6,850/ $13,700 0% $20 $10 $40 $40 $300 1 $0 2 $300 $40 $40 Silver EPO $1,750 20% $1,750/ $3,500 $6,350/ $12,700 20% 2 20% 2 20% 2 20% 2 20% 2 20% 2 20% 2 20% 2 20% 2 20% 2 Gold EPO $1,500 $10/$40 $1,500/ $3,000 $3,500/ $7,000 0% $10 $5 $40 $40 $175 1 $0 2 $0 2 $40 $40 Platinum EPO $500 $20/$40 $500/ $1,000 $1,000/ $2,000 0% $20 $10 $40 $40 $100 1 $0 2 $125 $20 $20 Platinum EPO $10/$25 $0/$0 $1,250/ $2,500 0% $10 $5 $25 $25 $175 1 $0 2 $150 $25 $25 Silver PPO $5,000 $10/$40 $5,000/ $10,000 $6,850/ $13,700 0% $10 $5 $40 $40 $175 1 $300 2 $300 2 $40 $40 Gold PPO $2,000/10% $20/$40 $2,000/ $4,000 $3,000/ $6,000 10% $20 $10 $40 $40 $100 1 10% 2 10% 2 $40 $40 Gold PPO $1,000 $20/$40 $1,000/ $2,000 $3,500/ $7,000 0% $20 $10 $40 $40 $175 1 $0 2 $0 2 $40 $40 Platinum PPO $10/$25 $0/$0 $1,250/ $2,500 0% $10 $5 $25 $25 $175 1 $0 2 $150 $25 $25 1 Waived if admitted 2 After deductible

UPMC Consumer Advantage Network: Premium Plan Name Deductible (I/F) Out-of-Pocket Maximum (I/F) Coinsurance PCP Visit E-visit Specialist Office Visit Urgent Care Emergency Department Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.) Lab and Other Services Silver HSA PPO $3,000 $3,000/ $6,000 $6,450/ $12,900 0% $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 Gold HSA PPO $1,350/10% $1,350/ $2,700 $3,425/ $6,850 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 Gold HSA PPO $1,400 $1,400/ $2,800 $3,425/ $6,850 0% $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 Gold HSA PPO $1,750 $1,750/ $3,500 $3,425/ $6,850 0% $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 UPMC HealthyU Network: Premium Plan Name Deductible (I/F) Out-of-Pocket Maximum (I/F) Coinsurance PCP Visit E-visit Specialist Office Visit Urgent Care Emergency Department Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.) Lab and Other Services Gold HIA PPO $2,500/10% $2,500/ $5,000 $3,425/ $6,850 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 Platinum HIA PPO $1,350/10% $1,350/ $2,700 $2,000/ $4,000 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 10% 2 1 Waived if admitted 2 After deductible

Pharmacy UPMC Health Plan features a pharmacy network of more than 30,000 pharmacies nationwide, including Giant Eagle, Kmart, Rite Aid, Target, CVS, Walmart, Sam s Club, and Wegmans (Erie locations). UPMC Health Plan produces the Advantage Choice formulary for our small market groups. We offer this formulary in searchable format at www.upmchealthplan.com. UPMC Health Plan contracts with Express Scripts Inc. to provide your employees with convenient home delivery of certain maintenance medications. With home delivery, your employees will: Receive up to a 90-day supply of most drugs, plus refills. Enjoy strict quality and safety controls on all prescriptions. For more information, visit www.upmchealthplan.com. UPMC Small Business Advantage and UPMC Inside Advantage Options During deductible period and after the deductible has been met Generic Preferred Brand Non-Preferred Brand Specialty $10 $40 $75 $95 $15 $30 $50 $95 Copayment (generic/preferred/non-preferred and/or specialty) Retail (30-day supply) Mail Order (90-day supply) $10/$40/$75/$95 $20/$80/$150 $15/$30/$50/$95 $30/$60/$100 UPMC HealthyU Options: Integrated During deductible period Actual drug cost After the deductible has been met Generic Preferred Brand Non-Preferred Brand Specialty $10 $40 $75 $95 $15 $30 $50 $95 Copayment (generic/preferred/non-preferred and/or specialty) - after the deductible has been met Retail (30-day supply) Mail Order (90-day supply) $10/$40/$75/$95 $20/$80/$150 $15/$30/$50/$95 $30/$60/$100 UPMC Consumer Advantage Options: Integrated During deductible period After the deductible has been met Actual drug cost Generic Preferred Brand Non-Preferred Brand Specialty $10 $40 $75 $95 $15 $30 $50 $95 Copayment (generic/preferred/non-preferred and/or specialty) - after the deductible has been met Retail (30-day supply)* Mail Order (90-day supply)* $10/$40/$75/$95 $20/$80/$150 $15/$30/$50/$95 $30/$60/$100 *If the brand-name drug is dispensed instead of the generic equivalent, member must pay the copayment associated with the brand-name drug as well as the price difference between the brand-name drug and the generic drug.

Vision and dental plan options By offering UPMC Vision Advantage and UPMC Dental Advantage to your employees, they will receive more integrated services from UPMC Health Plan. Our Health Care Concierge team can answer questions about all benefits purchased through UPMC Health Plan at one number or during one online chat session. Plus, your employees will have access to benefits and information for all products through MyHealth OnLine, our secure member website. UPMC Vision Advantage Features: Your employees are eligible for discounts on LASIK procedures at UPMC Eye Center, QualSight, and TLC Vision. Your employees receive a 20 percent discount on exams and lenses purchased through a participating UPMC Vision Advantage provider before their next eligibility period. Discount does not apply to contact lenses. UPMC Vision Advantage offers Basic, Standard, and Premium plan models, plus a vast network of vision providers. Basic Benefit In-Network Out-of-Network Copayment (applies to vision exam) $15 N/A Employee/Spouse/ Adult Dependents Frequency Children Through Age 18 Examination (less copayment) 100% $30 24 months 24 months Lenses (for glasses) Single Vision 20% Discount Not Covered Not Covered Not Covered Bifocal 20% Discount Not Covered Not Covered Not Covered Trifocal 20% Discount Not Covered Not Covered Not Covered Polycarbonate Lens Material 20% Discount Not Covered Not Covered Not Covered Frames 20% Discount Not Covered Not Covered Not Covered Contact Lenses (in lieu of glasses) Contact Lens Fitting and Follow-Up Not Covered Not Covered Not Covered Not Covered Contact Lens Material Not Covered Not Covered Not Covered Not Covered

Standard Benefit In-Network Out-of-Network Copayment (applies to vision exam) $15 N/A Employee/Spouse/ Adult Dependents Frequency Children Through Age 18 Examination (less copayment) 100% $40 24 months 12 months Lenses (for glasses) Lens reimbursement percentage is based on the base cost of the lens and does not include overages or lens add-ons. Out-of-network amount reflects the total amount reimbursed for services. Single Vision 100% $40 24 months 12 months Bifocal 100% $50 24 months 12 months Trifocal 100% $75 24 months 12 months Polycarbonate Lens Material Available in-network at no cost for children under age 19 100% Not Covered Not Covered 12 months UPMC Vision Advantage covers progressive lenses at 100% of the base cost of the lens when treated by a participating provider. Any additional charges above the base cost are not covered and are to be billed to the member. Payment may vary based on the type of lens billed to the plan. Progressive lenses received from a non-participating provider are reimbursed at $75. Frames Frame reimbursement is based on retail value. The plan will reimburse the participating provider 70% of the member s maximum for frames. The remaining 30% is a contractual discount to the plan and cannot be billed to the member. Any remainder above the member s frame allowance is to be charged to the member, minus a 20% discount, and can be collected at the time of service when a participating provider is used. Frames $60 $35 24 months 24 months Contact Lenses (in lieu of glasses) Contact lens fitting and follow-up reimbursement is separate from contact lens material. For specialty contact lens evaluation, the provider may bill the patient the difference between the provider s billed charges and the plan/member allowance. Provider cannot balance bill for standard lens evaluation when received in-network. Contact lens material is reimbursed at 100% of billed charges up to the member s plan maximum when a participating provider is used. Contact Lens Fitting and Follow-Up $50 $40 24 months 12 months Contact Lens Material $75 $60 24 months 12 months Standard - No Copay Benefit In-Network Out-of-Network Employee/Spouse/ Adult Dependents Frequency Children Through Age 18 Copayment None N/A Examination 100% $40 24 months 12 months Lenses (for glasses) Lens reimbursement percentage is based on the base cost of the lens and does not include overages or lens add-ons. Out-of-network amount reflects the total amount reimbursed for services. Single Vision 100% $40 24 months 12 months Bifocal 100% $50 24 months 12 months Trifocal 100% $75 24 months 12 months Polycarbonate Lens Material Available in-network at no cost for children under age 19 100% Not Covered Not Covered 12 months UPMC Vision Advantage covers progressive lenses at 100% of the base cost of the lens when treated by a participating provider. Any additional charges above the base cost are not covered and are to be billed to the member. Payment may vary based on the type of lens billed to the plan. Progressive lenses received from a non-participating provider are reimbursed at $75. Frames Frame reimbursement is based on retail value. The plan will reimburse the participating provider 70% of the member s maximum for frames. The remaining 30% is a contractual discount to the plan and cannot be billed to the member. Any remainder above the member s frame allowance is to be charged to the member, minus a 20% discount, and can be collected at the time of service when a participating provider is used. Frames $60 $35 24 months 24 months Contact Lenses (in lieu of glasses) Contact lens fitting and follow-up reimbursement is separate from contact lens material. For specialty contact lens evaluation, the provider may bill the patient the difference between the provider s billed charges and the plan/member allowance. Provider cannot balance bill for standard lens evaluation when received in-network. Contact lens material is reimbursed at 100% of billed charges up to the member s plan maximum when a participating provider is used. Contact Lens Fitting and Follow-Up $50 $40 24 months 12 months Contact Lens Material $75 $60 24 months 12 months

Premium Benefit In-Network Out-of-Network Copayment (applies to vision exam) $15 N/A Employee/Spouse/ Adult Dependents Frequency Children Through Age 18 Examination (less copayment) 100% $40 12 months 12 months Lenses (for glasses) Lens reimbursement percentage is based on the base cost of the lens and does not include overages or lens add-ons. Out-of-network amount reflects the total amount reimbursed for services. Single Vision 100% $40 12 months 12 months Bifocal 100% $50 12 months 12 months Trifocal 100% $75 12 months 12 months Polycarbonate Lens Material Available in-network at no cost for children 100% Not Covered Not Covered 12 months under age 19 UPMC Vision Advantage covers progressive lenses at 100% of the base cost of the lens when treated by a participating provider. Any additional charges above the base cost are not covered and are to be billed to the member. Payment may vary based on the type of lens billed to the plan. Progressive lenses received from a non-participating provider are reimbursed at $75. Frames Frame reimbursement is based on retail value. The plan will reimburse the participating provider 70% of the member s maximum for frames. The remaining 30% is a contractual discount to the plan and cannot be billed to the member. Any remainder above the member s frame allowance is to be charged to the member, minus a 20% discount, and can be collected at the time of service when a participating provider is used. Frames $100 $55 12 months 12 months Contact Lenses (in lieu of glasses) Contact lens fitting and follow-up reimbursement is separate from contact lens material. For specialty contact lens evaluation, the provider may bill the patient the difference between the provider s billed charges and the plan/member allowance. Provider cannot balance bill for standard lens evaluation when received in-network. Contact lens material is reimbursed at 100% of billed charges up to the member s plan maximum when a participating provider is used. Contact Lens Fitting and Follow-Up $50 $40 12 months 12 months Contact Lens Material $100 $80 12 months 12 months Premium - No Copay Benefit In-Network Out-of-Network Employee/Spouse/ Adult Dependents Frequency Children Through Age 18 Copayment None N/A Examination 100% $40 12 months 12 months Lenses (for glasses) Lens reimbursement percentage is based on the base cost of the lens and does not include overages or lens add-ons. Out-of-network amount reflects the total amount reimbursed for services. Single Vision 100% $40 12 months 12 months Bifocal 100% $50 12 months 12 months Trifocal 100% $75 12 months 12 months Polycarbonate Lens Material Available in-network at no cost for children 100% Not Covered Not Covered 12 months under age 19 UPMC Vision Advantage covers progressive lenses at 100% of the base cost of the lens when treated by a participating provider. Any additional charges above the base cost are not covered and are to be billed to the member. Payment may vary based on the type of lens billed to the plan. Progressive lenses received from a non-participating provider are reimbursed at $75. Frames Frame reimbursement is based on retail value. The plan will reimburse the participating provider 70% of the member s maximum for frames. The remaining 30% is a contractual discount to the plan and cannot be billed to the member. Any remainder above the member s frame allowance is to be charged to the member, minus a 20% discount, and can be collected at the time of service when a participating provider is used. Frames $100 $55 12 months 12 months Contact Lenses (in lieu of glasses) Contact lens fitting and follow-up reimbursement is separate from contact lens material. For specialty contact lens evaluation, the provider may bill the patient the difference between the provider s billed charges and the plan/member allowance. Provider cannot balance bill for standard lens evaluation when received in-network. Contact lens material is reimbursed at 100% of billed charges up to the member s plan maximum when a participating provider is used. Contact Lens Fitting and Follow-Up $50 $40 12 months 12 months Contact Lens Material $100 $80 12 months 12 months Out-of-network reimbursement is based on Usual, Customary, and Reasonable as determined by UPMC Vision Advantage. Members are eligible for a 20% discount on additional examinations, frames, and lenses for glasses received from a participating provider prior to the next eligibility period. 20% discount does not apply to contact lenses. Lens reimbursement is based on the base cost of the lens and does not include coverage for lens add-ons and/or treatments (such as coatings, tinting, polarization, photochromatics). These services are not covered by or to be billed to UPMC Vision Advantage. Participating providers are to discount these services by 20%. Note: This does not apply to the Basic Plan. UPMC Vision Advantage participants are eligible for discounts on LASIK surgery when received by one of the following preferred providers: UPMC Eye Center, TLC Vision, and QualSight.

Essential Health Benefits Rider for Members Under Age 19 Benefit In-Network 1 Out-of-Network 2 Frequency Examination 100% $30 12 months Lenses (for glasses) 3 Single Vision 100% $25 12 months Bifocal 100% $35 12 months Trifocal 100% $45 12 months Progressive 100% $45 12 months Frames Frames 100% $30 12 months Contact Lenses (in lieu of glasses) if deemed medically necessary Contact lens fitting and follow-up reimbursement is separate from contact lens material. Contact Lens Fitting and Follow-up 100% $35 12 months Contact Lens Material 100% $75 12 months 1 In-network reimbursement is based on the percentage of provider reimbursement. The provider is not permitted to bill the member for the difference for any services unless otherwise stated. The provider may charge the member a copayment for optional lenses and treatments as described below. 2 Out-of-network reimbursement is based on Usual, Customary, and Reasonable rates as determined by UPMC Vision Advantage. 3 Lens reimbursement includes reimbursements for polycarbonate lenses. Members are eligible for a 20% discount on additional examinations, frames, and lenses for glasses received from a participating provider prior to their next eligibility period. The 20% discount does not apply to contact lenses. UPMC Vision Advantage members are eligible for discounts on LASIK surgery when it is received by one of the following preferred providers: UPMC Eye Center, TLC Vision, and QualSight. Members may purchase elective, non-medical contacts (including evaluation and fitting) at their own expense. Participating vision providers are to discount the contact lens evaluation and fitting by 20%. Discount does not apply to contact lens material. Optional lenses and treatments are available in-network only for additional copayment and may be billed by the provider. Optional Lenses and Treatments Copayment Anti-Reflective Coating $20 Hi-Index Lenses $25 Tint Photochromatic $25 Polarized Lenses $20 Premium Progressives $90

UPMC Dental Advantage UPMC Dental Advantage offers Basic, Standard, and Premium plan models, plus a vast network of dentists. The plans are designed to encourage regular preventive care and foster open communication between members and dentists regarding recommended treatment plans. Features: Prior authorization is not required for major services. Enhanced benefits include one additional cleaning for members who are pregnant during the course of pregnancy; increased coverage for non-surgical periodontal treatment, including topical application of fluoride for adults with a history of surgical periodontal treatment; and coverage for microbial tests and brush biopsies. Plan In-Network Covered Amount/Class I/Class II/ Class III/Deductible/ Plan Year Maximum/ Ortho Lifetime Maximum Service Class Deductible Annual Maximum Ortho Coverage Ortho Lifetime Maximum Class I Class II Class III $0 $50 $75 $1,000 $1,500 $2,000 Yes No $1,000 Out-of- Network Coverage Basic Basic 100/0/0/$0 ü ü ü 80/0/0 Basic 100/0/0/$50 ü ü ü 80/0/0 Basic 100/0/0/$75 ü ü ü 80/0/0 Standard Standard 100/50/50/$0/ $1,500/No Ortho ü ü ü ü ü ü 80/40/20 Standard 100/50/50/$0/ $1,500/Ortho/$1,000 Standard 100/50/50/$75/ $2,000/No Ortho Premium Premium 100/80/50/$0/ $1,500/No Ortho Premium 100/80/50/$0/ $1,500/Ortho/$1,000 Premium 100/70/50/$0/ $1,000/No Ortho Premium 100/70/50/$50/ $1,000/No Ortho Premium 100/70/50/$0/ $1,500/No Ortho Premium 100/70/50/$50/ $1,500/No Ortho ü ü ü ü ü ü ü 80/40/20 ü ü ü ü ü ü 80/40/20 ü ü ü ü ü ü 80/60/40 ü ü ü ü ü ü ü 80/60/40 ü ü ü ü ü ü 80/40/20 ü ü ü ü ü ü 80/40/20 ü ü ü ü ü ü 80/40/20 ü ü ü ü ü ü 80/40/20

Essential Health Benefits Rider for Members Under Age 19 UPMC Dental Advantage will cover the services set forth below, which are related to the dental benefits provided in accordance with UPMC Dental Advantage policies and procedures. In the event that the terms and conditions set forth in other dental benefit materials you have been provided conflict with those set forth in this plan document, the terms and conditions of this plan document control. Plan Year Deductible: Class I (Out-of-Network Only), Class II, Class III In-Network Out-of-Network 1 $50 Individual/ $75 Individual/$150 Eligible $200 Eligible Dependents (2+) Dependents (2+) Class I: Diagnostic/Preventive $150 $200 Exams and Prophylaxis Payable for two services in a benefit year Bitewings Payable for two services in a benefit year up to age 14; one service in a benefit year for 14+ years Complete Series and Panoramic Films Payable for one service in a 36-month period and is not covered for members under the age of 5 Topical Fluoride Payable to age 19 for two services in a benefit year Periodontal Scaling/Root Planing Payable for one service every 24 months Sealants Payable to age 14 for one service per tooth (molar) every 36 months Space Maintainers Payable to age 19 Class II: Basic Services 70% 60% Amalgam and Composite Fillings Payable Pulpal Therapy/Anterior and Posterior Payable Endodontic Therapy (Including treatment plan, clinical procedures, and follow-up care) Payable Extractions and Oral Surgery Payable Class III: Major Services 50% 40% Crowns Payable for one service per tooth in a 60-month period Inlay/Onlay metallic/porcelain/resin up to 4 surfaces Payable for one service per tooth in a 60-month period Implants Payable for one service per tooth, per lifetime Prosthodontics Payable Dentures Complete and Partial Payable for one service in a 60-month period Prefabricated Stainless Steel Crown/Primary Tooth Payable for one service per tooth in a 60-month period Orthodontics: Subject to Medical Deductible 2 50% Not covered The services above are not all-inclusive they include only the most common dental procedures in a class or service grouping. UPMC Dental Advantage encourages, but does not require, members to seek predetermination for major services, such as crowns and bridges, to obtain the most accurate payment estimate. Additional plan information can be found in the Certificate of Insurance. Copayments, coinsurance, and deductibles for dental benefits apply toward satisfaction of the combined out-of-pocket maximum specified in your Medical Schedule of Benefits. Services are covered at 100% after the out-of-pocket maximum is satisfied. 1 Out-of-network reimbursement is based on Usual, Customary, and Reasonable charges as determined by UPMC Dental Advantage. The member is responsible for the difference between those charges and the provider s fee. 2 Orthodontic coverage is subject to the Medical Deductible, which can be found in the Medical Schedule of Benefits. Orthodontic services are only payable when deemed medically necessary by the plan. Additional plan information can be found in the Certificate of Insurance. This Rider may expand or restrict the benefits set forth in your UPMC Dental Advantage Pediatric Dental Certificate of Insurance. See the Certificate of Insurance for the details of the terms of coverage for your health benefit plan. In the event that the terms of your Certificate of Insurance conflict with this Rider, the terms of this Rider prevail.

Value-added benefits and services Health coaching We offer lifestyle improvement and condition management programs at no cost to your employees. Your employees work one-on-one with a health coach over the phone. Programs include: MyHealth Less Stress MyHealth Weigh to Wellness MyHealth Eating Well MyHealth Step Up to Wellness MyHealth Ready to Quit MyHealth OnLine MyHealth OnLine is a secure website that employees can personalize for their goals and needs. Here, they can take the MyHealth Questionnaire to find out what their health risks are. In return, they get a list of activities recommended just for them to reduce risk for chronic disease, feel better, and meet their goals. They can also research health conditions, access treatment cost and comparison tools, see their claims and coverage information, and more. UPMC AnywhereCare With UPMC AnywhereCare, employees can get treatment for colds and flu, strep throat, poison ivy, and other nonemergency conditions right from their computer. They receive a care plan and prescription (if needed), usually within 30 minutes. The cost is less than or the same as a visit with their primary care physician. Your employees can also connect with leading dermatologists and get treatment for skin conditions and disorders. These services are available 24/7. Member must be in the states of Pennsylvania or Maryland for the duration of the online visit. For e-visits with a dermatologist, member must be in the state of Pennsylvania for the duration of the online visit. MyHealth Advice Line Your employees can speak to a registered nurse anytime, day or night, when they have a health question or medical concern by calling the UPMC MyHealth Advice Line. Health Care Concierge Your employees receive fast, personal service from our UPMC Health Plan Health Care Concierge team. Our customer service team strives to resolve questions and concerns in one phone call. The information provided for these benefits is for informational purposes only. Actual benefits are subject to the terms and conditions of the certificate of coverage. LifeSolutions employee assistance program Workplace, personal, and family issues can be distracting to employees, resulting in lost productivity and missed work. LifeSolutions offers a host of resources to help your employees feel better and stay focused. Benefits include coaching and counseling over the phone and numerous online resources, such as financial calculators and self-assessments. UPMC FlexAdvantage Flexible spending accounts Flexible spending accounts (FSAs) from UPMC FlexAdvantage help your employees save money using pretax dollars. We offer health care, dependent care, and limited purpose FSAs as well as commuter transportation accounts. Health savings accounts Health savings accounts from UPMC FlexAdvantage help your employees pay for out-of-pocket health care expenses. These accounts must be paired with a qualified high-deductible health plan. Both the employer and employee can contribute. The balance can be carried over from year to year. The employee owns the account and can take it when he or she changes employers. Employer benefits: UPMC FlexAdvantage can be purchased as a single HSA solution for employers with multi-carrier offerings. Limited purpose FSAs can be used in conjunction with HSAs for employers looking to enhance benefit offerings for employees. Convenient Employer OnLine resource tool for easy account administration with single sign-on access. Designated account manager. HSA reporting capability. Ancillary services UPMC COBRA Advantage We administer monthly billing and collection from the COBRA participant, monitor nonpayment, and provide late payment notices. We also handle open enrollment mailing, carrier updates, and other vital communications. Retiree billing Our Web-based system allows you to coordinate enrollment, billing, and reimbursement of retiree benefits. Electronic payment of monthly premiums eliminates the need to write checks. This information can be accessed 24/7.

The Affordable Care Act

The impact of the Affordable Care Act Note: To remain in compliance with the Affordable Care Act (ACA), UPMC Health Plan has incorporated these factors into our plan offerings for employer groups within our small market portfolio: Actuarial Value The ACA requires that all new small market products meet specific actuarial values, which are the percentage of medical expenses, on average, paid by the insurer. The ACA uses metal levels of Platinum, Gold, Silver, and Bronze to correspond with actuarial values of 90%, 80%, 70%, and 60%, respectively. Issuers must offer plans within +/- 2% of these values. Community Rating Under community rating, premiums may vary based only upon the following four factors: 1. Rating area There are nine rating regions in the state. A list of these regions by county is available from the Centers for Medicare and Medicaid Services (CMS). 2. Single vs. family coverage Premiums for family coverage will be based on premiums for each individual in a family. Under this approach, we will add the individual rate for each family member to arrive at a family premium. All family members age 21 and older will be added. However, only the three oldest covered children under age 21 will be counted. 3. Tobacco use Premiums charged for tobacco users may be up to 1.5 times higher than premiums charged for non-tobacco users. 4. Age Premiums based on age will work like this: Adults (ages 21-63) may have different premiums based on age. But the difference may not be more than three-to-one. That is, the premium charged to the oldest adult may not be more than three times higher than the premium charged to the youngest adult (age 21 or older). For children ages 0 to 20 years, the age-adjusted premiums must be the same for all individuals. For adults 64 years of age or older, age-adjusted premiums must be the same for all individuals. The premium charged at renewal or point of sale remains as sold until the next renewal date, when rates will be adjusted based on age bracket changes. Essential Health Benefits (EHBs) EHBs are a specific set of health benefits, items, and services that must be covered by health plans in the individual and small group markets. These benefits include, among other things, pediatric dental and vision services. Our pediatric dental and vision services will be administered by UPMC Dental Advantage and UPMC Vision Advantage. UPMC Health Plan has embedded these benefits into its medical plans, which makes it easy for employers to administer and comply with ACA mandates. Please refer to the Schedules of Benefits, which define the coverage for dependents. Please note that if a dependent turns 19 years of age during a plan year, that dependent will continue to have Essential Health Benefits coverage until the end of the dependent s birth date month.

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