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A Summary of Covered Benefits – Comprehensive Major Medical. Medical Insurance The Board shall provide a comprehensive major medical plan, as described below, along with prescription drug benefits. The Board shall arrange to have the employees ten percent (10%) cost calculated for pretax compensation. The Minimum Value Based plan, as described below, shall also be available for those eligible employees who elect coverage under it. Sheffield-Sheffield Lake City Schools Summary of Plan Designs Premium Min. Value Based Design for ACA In-Network Deductible (In-network) $750/$1,500 $4,000/$8,000 - Earned Incentive Award ($250)/($500) ($250/$500) Deductible (In-network) $500/$1,000 $3,750/$7,500 Coinsurance 90% 70% Coinsurance Out-of-Pocket Max (does not include deductible) $1,500/$3,000 $2,250/$4,500 Out-of-Pocket Max (includes deductibles, coinsurance and medical/drug copays) $6,600/$13,200 $6,600/$13,200 Out-of-Network Deductible (Out-of-network) $1,500/$3,000 $4,000/$8,000 Coinsurance 60% 50% Coinsurance Out-of-Pocket Max (does not include deductible) $3,000/$6,000 $10,000/$20,000 Out-of-Pocket Max (includes deductibles, coinsurance and medical/drug copays)) Unlimited Unlimited Office and Emergency Visits OV Copay $25 $50 Urgent Care Visit $40 $100 Specialist Visit $40 $100 ER Copay - Emergency $100 $300 ER Copay - Non-Emergency $200 $300 Preventive Services Immunizations 100% In-network 100% In-network Routine Physical 100% In-network 100% In-network Routine PSA 100% In-network 100% In-network Endoscopies 100% In-network 100% In-network Pap Test Exam 100% In-network 100% In-network PPACA Expanded Wellness Svcs 100% In-network 100% In-network Prescription Drug Benefit Retail Drug Card $10/$25/$50 Ded. then $10/$50/$100 Mail Order $20/$50/$100 Ded. then $20/$100/$200 Specialty Medications $60 Ded. then $200 Step Therapy YES YES Mandatory Mail Order YES YES Maintenance Choice YES YES All maintenance drugs shall be mandatory mail order or maintenance choice. The Board shall offer a Section 125 Flexible Spending Account, whereby participants may elect to contribute pre-tax contributions to offset eligible medical expenses and the employee’s share of premiums.

A Summary of Covered Benefits – Comprehensive Major Medical. Medical Insurance The Board shall provide a comprehensive major medical plan, as described below, along with prescription drug benefits. The Board shall arrange to have the employees ten percent (10%) cost calculated for pretax compensation. The Minimum Value Based plan, as described below, shall also be available for those eligible employees who elect coverage under it. Sheffield-Sheffield Lake City Schools Summary of Plan Designs Premium MinP remium M in. Value Based Design for ACA In-Network Deductible (In-network) $750/$1,500 $4,000/$8,000 - Earned Incentive Award ($250)/($500) (( $250/$500) Deductible (In-network) $500/$1,000 $3,750/$7,500 Coinsurance 90% 70% Coinsurance Out-of-Pocket Max (does not include deductible) $1,500/$3,000 $2,250/$4,500 Out-of-Pocket Max (includes deductibles, coinsurance and medical/drug copays) $6,600/$13,200 $6,600/$13,200 Out-of-Network Deductible (Out-of-network) $1,500/$3,000 $4,000/$8,000 Coinsurance 60% 50% Coinsurance Out-of-Pocket Max (does not include deductible) $3,000/$6,000 $10,000/$20,000 Out-of-Pocket Max (includes deductibles, coinsurance and medical/drug copays)) Unlimited Unlimited Office and Emergency Visits OV Copay $25 $50 Urgent Care Visit $40 $100 Specialist Visit $40 $100 ER Copay - Emergency $100 $300 ER Copay - Non-Emergency $200 $300 Preventive Services Immunizations 100% In-network 100% In-network Routine Physical 100% In-network 100% In-network Routine PSA 100% In-network 100% In-network Endoscopies 100% In-network 100% In-network Pap Test Exam 100% In-network 100% In-network PPACA Expanded Wellness Svcs 100% In-network 100% In-network Prescription Drug Benefit Retail Drug Card $10/$25/$50 Ded. then $10/$50/$100 Mail Order $20/$50/$100 Ded. then $20/$100/$200 Specialty Medications $60 Ded. then $200 Step Therapy YES YES Mandatory Mail Order YES YES Maintenance Choice YES YES All maintenance drugs shall be mandatory mail order or maintenance choice. The Board shall offer a Section 125 Flexible Spending Account, whereby participants may elect to contribute pre-tax contributions to offset eligible medical expenses and the employee’s share of premiums.