Common use of Preventative Care Clause in Contracts

Preventative Care. Physical Examination - Child Physical Examination - Adult Vision Examination / one every two years OB/GYN visit Mammography Hearing Screening / One every year No copayment No Copayment No Copayment $ 15 Copay No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance OUTPATIENT CARE: Physician Office Visit Specialist Office Visit Outpatient Surgical Services Diagnostic X-Ray / Lab Examination Complex Imaging (MRI, CAT, PET, etc ) Prenatal and Postnatal Maternity Care Outpatient Rehabilitation $ 15 copay $ 15 copay $ 50 per visit No charge No charge $ 15 initial visit only No Charge (50 visit max) Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance MENTAL HEALTH CARE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance SUBSTANCE ABUSE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance ALLERGY CARE: Office Visit Injections $ 15 copay No charge Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOSPITAL CARE: Semi Private Hospital Admission Skilled Nursing and Rehabilitation Facilities Rehabilitative services $100 per admission $100 per admission No charge Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOME HEALTH CARE: No charge $50 Ded & Coinsurance Subject to Deductible Deductible & Coinsurance EMERGENCY CARE: Walk-in Center Emergency Room (waived fee if admitted) Ambulance Service Urgent Care $ 15 per visit $ 50 per visit No charge $ 25 per visit Deductible & Coinsurance $ 50 per visit No charge Not covered Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Same as In-network Same as In-network Not Covered

Preventative Care. Physical Examination - Child Physical Examination - Adult Vision Examination / one every two years OB/GYN visit Mammography Hearing Screening / One every year No copayment No Copayment No Copayment $ 15 Copay No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No copayment No Copayment No Copayment $ 10 Copay No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance OUTPATIENT CARE: Physician Office Visit Specialist Office Visit Outpatient Surgical Services Diagnostic X-Ray / Lab Examination Complex Imaging (MRI, CAT, PET, etc ) Prenatal and Postnatal Maternity Care Outpatient Rehabilitation $ 15 copay $ 15 copay $ 50 per visit No charge No charge $ 15 initial visit only No Charge (50 visit max) Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance $ 10 copay $ 10 Copay No charge No charge No charge $ 10 initial visit only $ 10 copay (unlimited) Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance MENTAL HEALTH CARE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance SUBSTANCE ABUSE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance ALLERGY CARE: Office Visit Injections $ 15 copay No charge Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOSPITAL CARE: Semi Private Hospital Admission Skilled Nursing and Rehabilitation Facilities Rehabilitative services $100 per admission $100 per admission No charge Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No charge No charge No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOME HEALTH CARE: No charge $50 Ded & Coinsurance No charge Subject to Deductible Deductible & Coinsurance EMERGENCY CARE: Walk-in Center Emergency Room (waived fee if admitted) Ambulance Service Urgent Care $ 15 per visit $ 50 per visit No charge $ 25 per visit Deductible & Coinsurance $ 50 per visit No charge Not covered $ 10 per visit $ 50 per visit No charge $ 25 per visit Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Same as In-network Same as In-network Not Covered

Preventative Care. Physical Examination - Child No copayment Deductible & Coinsurance No copayment No Copayment Deductible & Coinsurance Physical Examination - Adult No Copayment Deductible & Coinsurance No Copayment No Copayment Deductible & Coinsurance Vision Examination / one every two years No Copayment Deductible & Coinsurance No Copayment No Copayment Deductible & Coinsurance OB/GYN visit $ 15 Copay Deductible & Coinsurance $ 10 Copay No Copayment Deductible & Coinsurance Mammography No Copayment Deductible & Coinsurance No Copayment No Copayment Deductible & Coinsurance Hearing Screening / One every year No copayment No Copayment No Copayment $ 15 Copay No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance OUTPATIENT CARE: Physician Office Visit $ 15 copay Deductible & Coinsurance $ 10 copay Subject to Deductible Deductible & Coinsurance Specialist Office Visit $ 15 copay Deductible & Coinsurance $ 10 Copay Subject to Deductible Deductible & Coinsurance Outpatient Surgical Services $ 50 per visit Deductible & Coinsurance No charge Subject to Deductible Deductible & Coinsurance Diagnostic X-Ray / Lab Examination No charge Deductible & Coinsurance No charge Subject to Deductible Deductible & Coinsurance Complex Imaging (MRI, CAT, PET, etc ) Prenatal and Postnatal Maternity Care Outpatient Rehabilitation $ 15 copay $ 15 copay $ 50 per visit No charge No charge $ 15 initial visit only No Charge (50 visit max) Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible No charge Subject to Deductible Deductible & Coinsurance Prenatal and Postnatal Maternity Care $ 15 initial visit only Deductible & Coinsurance $ 10 initial visit only Subject to Deductible Deductible & Coinsurance Outpatient Rehabilitation No Charge Deductible & Coinsurance $ 10 copay Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance (50 visit max) (unlimited) MENTAL HEALTH CARE: Outpatient Treatment Inpatient Treatment $ 15 copay Deductible & Coinsurance $ 10 copay Subject to Deductible Deductible & Coinsurance Inpatient Treatment $100 per admission Deductible & Coinsurance Deductible & Coinsurance No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance SUBSTANCE ABUSE: Outpatient Treatment Inpatient Treatment $ 15 copay Deductible & Coinsurance $ 10 copay Subject to Deductible Deductible & Coinsurance Inpatient Treatment $100 per admission Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible No charge Subject to Deductible Deductible & Coinsurance ALLERGY CARE: $ 15 copay Deductible & Coinsurance ALLERGY CARE: Office Visit Injections $ 15 10 copay No charge Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Office Visit Injections No charge Deductible & Coinsurance No charge Subject to Deductible Deductible & Coinsurance HOSPITAL CARE: Semi Private Hospital Admission Skilled Nursing and Rehabilitation Facilities Rehabilitative services $100 per admission $100 per admission No charge Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible No charge Subject to Deductible Deductible & Coinsurance Skilled Nursing and Rehabilitation Facilities $100 per admission Deductible & Coinsurance No charge Subject to Deductible Deductible & Coinsurance Rehabilitative services No charge Deductible & Coinsurance No charge HOME HEALTH CARE: No charge $50 Ded & Coinsurance No charge Subject to Deductible Deductible & Coinsurance EMERGENCY CARE: Walk-in Center $ 15 per visit Deductible & Coinsurance $ 10 per visit Subject to Deductible Deductible & Coinsurance Emergency Room (waived fee if admitted) Ambulance Service Urgent Care $ 15 50 per visit $ 50 per visit $ 50 per visit Subject to Deductible Same as In-network Ambulance Service No charge No charge No charge Subject to Deductible Same as In-network Urgent Care $ 25 per visit Not covered $ 25 per visit Subject to Deductible Not Covered Prescription Drugs: Generic Tier 1 Drugs $ 5 Deductible & Coinsurance $ 50 per visit No charge Not covered Subject to Deductible Subject to Deductible Subject to Deductible 5 Subject to Deductible Deductible & Coinsurance Same as InListed Brand Tier 2 Drugs $ 20 Deductible & Coinsurance $ 20 Subject to Deductible Deductible & Coinsurance Non-network Same as In-network Not Coveredlisted Brand Tier Drugs $ 30 Deductible & Coinsurance $ 30 Subject to Deductible Deductible & Coinsurance Mail Order $ 0 Deductible & Coinsurance $ 0 Subject to Deductible Deductible & Coinsurance Annual maximum Unlimited Deductible & Coinsurance Unlimited Unlimited Deductible & Coinsurance APPENDIX B – INSURANCE SUMMARY *Note: The PPO and HMO are not eligible plans for employees effective 7/1/2018. The PPO is an eligible plan for retirees.

Preventative Care. Physical Examination - Child Physical Examination - Adult Vision Examination / one every two years OB/GYN visit Mammography Hearing Screening / One every year years No copayment No Copayment No Copayment $ 15 Copay No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No copayment No Copayment No Copayment $ 10 Copay No Copayment No Copayment No copayment No Copayment No Copayment No Copayment No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance OUTPATIENT CARE: Physician Office Visit Specialist Office Visit Outpatient Surgical Services Diagnostic X-Ray / Lab Examination Complex Imaging (MRI, CAT, PET, etc ) Prenatal and Postnatal Maternity Care Outpatient Rehabilitation $ 15 copay $ 15 copay $ 50 per visit No charge No charge $ 15 initial visit only No Charge (50 visit max) Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance $ 10 copay $ 10 Copay No charge No charge No charge $ 10 initial visit only $ 10 copay (unlimited) Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance MENTAL HEALTH CARE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance SUBSTANCE ABUSE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance ALLERGY CARE: Office Visit Injections $ 15 copay No charge Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOSPITAL CARE: Semi Private Hospital Admission Skilled Nursing and Rehabilitation Facilities Rehabilitative services $100 per admission $100 per admission No charge Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No charge No charge No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOME HEALTH CARE: No charge $50 Ded & Coinsurance No charge Subject to Deductible Deductible & Coinsurance EMERGENCY CARE: Walk-in Center Emergency Room (waived fee if admitted) Ambulance Service Urgent Care $ 15 per visit $ 50 per visit No charge $ 25 per visit Deductible & Coinsurance $ 50 per visit No charge Not covered $ 10 per visit $ 50 per visit No charge $ 25 per visit Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Same as In-network Same as In-network Not Covered

Preventative Care. Physical Examination - Child No copayment Deductible & Coinsurance No copayment No Copayment Deductible & Coinsurance Physical Examination - Adult No Copayment Deductible & Coinsurance No Copayment No Copayment Deductible & Coinsurance Vision Examination / one every two years No Copayment Deductible & Coinsurance No Copayment No Copayment Deductible & Coinsurance OB/GYN XXX visit $ 15 Copay Deductible & Coinsurance $ 10 Copay No Copayment Deductible & Coinsurance Mammography No Copayment Deductible & Coinsurance No Copayment No Copayment Deductible & Coinsurance Hearing Screening / One every year No copayment No Copayment No Copayment $ 15 Copay No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance OUTPATIENT CARE: Physician Office Visit $ 15 copay Deductible & Coinsurance $ 10 copay Subject to Deductible Deductible & Coinsurance Specialist Office Visit $ 15 copay Deductible & Coinsurance $ 10 Copay Subject to Deductible Deductible & Coinsurance Outpatient Surgical Services $ 50 per visit Deductible & Coinsurance No charge Subject to Deductible Deductible & Coinsurance Diagnostic X-Ray / Lab Examination No charge Deductible & Coinsurance No charge Subject to Deductible Deductible & Coinsurance Complex Imaging (MRI, CAT, PET, etc ) Prenatal and Postnatal Maternity Care Outpatient Rehabilitation $ 15 copay $ 15 copay $ 50 per visit No charge No charge $ 15 initial visit only No Charge (50 visit max) Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible No charge Subject to Deductible Deductible & Coinsurance Prenatal and Postnatal Maternity Care $ 15 initial visit only Deductible & Coinsurance $ 10 initial visit only Subject to Deductible Deductible & Coinsurance Outpatient Rehabilitation No Charge Deductible & Coinsurance $ 10 copay Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance (50 visit max) (unlimited) MENTAL HEALTH CARE: Outpatient Treatment Inpatient Treatment $ 15 copay Deductible & Coinsurance $ 10 copay Subject to Deductible Deductible & Coinsurance Inpatient Treatment $100 per admission Deductible & Coinsurance Deductible & Coinsurance No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance SUBSTANCE ABUSE: Outpatient Treatment Inpatient Treatment $ 15 copay Deductible & Coinsurance $ 10 copay Subject to Deductible Deductible & Coinsurance Inpatient Treatment $100 per admission Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible No charge Subject to Deductible Deductible & Coinsurance ALLERGY CARE: $ 15 copay Deductible & Coinsurance ALLERGY CARE: Office Visit Injections $ 15 10 copay No charge Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Office Visit Injections No charge Deductible & Coinsurance No charge Subject to Deductible Deductible & Coinsurance HOSPITAL CARE: Semi Private Hospital Admission Skilled Nursing and Rehabilitation Facilities Rehabilitative services $100 per admission $100 per admission No charge Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible No charge Subject to Deductible Deductible & Coinsurance Skilled Nursing and Rehabilitation Facilities $100 per admission Deductible & Coinsurance No charge Subject to Deductible Deductible & Coinsurance Rehabilitative services No charge Deductible & Coinsurance No charge HOME HEALTH CARE: No charge $50 Ded & Coinsurance No charge Subject to Deductible Deductible & Coinsurance EMERGENCY CARE: Walk-in Center $ 15 per visit Deductible & Coinsurance $ 10 per visit Subject to Deductible Deductible & Coinsurance Emergency Room (waived fee if admitted) Ambulance Service Urgent Care $ 15 50 per visit $ 50 per visit $ 50 per visit Subject to Deductible Same as In-network Ambulance Service No charge No charge No charge Subject to Deductible Same as In-network Urgent Care $ 25 per visit Not covered $ 25 per visit Subject to Deductible Not Covered Prescription Drugs: Generic Tier 1 Drugs $ 5 Deductible & Coinsurance $ 50 per visit No charge Not covered Subject to Deductible Subject to Deductible Subject to Deductible 5 Subject to Deductible Deductible & Coinsurance Same as InListed Brand Tier 2 Drugs $ 20 Deductible & Coinsurance $ 20 Subject to Deductible Deductible & Coinsurance Non-network Same as In-network Not Coveredlisted Brand Tier Drugs $ 30 Deductible & Coinsurance $ 30 Subject to Deductible Deductible & Coinsurance Mail Order $ 0 Deductible & Coinsurance $ 0 Subject to Deductible Deductible & Coinsurance Annual maximum Unlimited Deductible & Coinsurance Unlimited Unlimited Deductible & Coinsurance APPENDIX B – INSURANCE SUMMARY *Note: The PPO and HMO are not eligible plans for employees effective 7/1/2018. The PPO is an eligible plan for retirees.