Common use of Preventive Care Clause in Contracts

Preventive Care. Routine Well Adult Care 100% 60% after deductible Includes: office visits, pap smear, mammogram, gynecological exam, routine physical examination, x- rays, laboratory tests, prostate specific antigen test, colonoscopies, sigmoidoscopies and anoscopy, proctosigmoidoscopy, medical tests and other preventive services as required by law. Routine Well Child Care 100% 60% after deductible Includes: office visits, routine physical examination, laboratory tests, x-rays, immunizations, and other Preventive services as required by law. Flu Shots 100% Paid Same As Network Eye Exam (including refractive exams) 100% after Copayment Limited to 1 per Calendar Year, unless otherwise required by law Not Covered Organ Transplants 80% after deductible Not Covered Other Medical Services and Supplies 80% after deductible 60% after deductible Drugs and Products included on the Select Drugs and Products List Require pre-certification and enrollment in the Select Drugs and Products Program Generic Drugs $10 copayment Formulary Brand Name Drugs $20 copayment Non-Formulary Brand Name Drugs $50 copayment Specialty Drugs May be available through the Select Drugs and Products Program Generic Drugs $20 copayment Formulary Brand Name Drugs $40 copayment Non-Formulary Brand Name Drugs $100 copayment NOTE: Charges for Prescription Drugs obtained through the Prescription Drug Benefit section will not apply to the Calendar Year Deductible. Prescription Drug expenses do apply to the Out-of-Pocket Maximum under Medical Benefits section of this Plan. Per Covered Person $2,800 $5,000 Per Family Unit $5,000 $10,000 Amounts applied to the Network Deductible and the Non-Network Deductible do not cross-apply. The Calendar Year deductible is waived for the following Covered Charges: - Network Preventive Care - Flu Shots Per Covered Person $2,800 $6,000 Per Family Unit $5,000 $12,000 The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum: Non-Precertification penalties Amounts over Usual and Reasonable Charge Amounts for products included on the Select Drugs and Products List Room, Board, and Miscellaneous Expenses 100% after deductible 80% after deductible Intensive Care Unit 100% after deductible 80% after deductible Surgical Facilities 100% after deductible 80% after deductible Other Outpatient Services 100% after deductible 80% after deductible Emergency Room Visit 100% after deductible Paid Same As Network Urgent Care Facility 100% after deductible 80% after deductible Skilled Nursing Facility 100% after deductible 180 day Calendar Year maximum 80% after deductible 60 day Calendar Year maximum Inpatient visits 100% after deductible 80% after deductible Office visits (including related services billed by the Physician) 100% after deductible 80% after deductible Surgery 100% after deductible 80% after deductible Anesthesia 100% after deductible Paid Same As Network Allergy services 100% after deductible 80% after deductible Diagnostic Testing (X-ray & Lab) 100% after deductible 80% after deductible Independent Laboratory expenses 100% after deductible Paid Same As Network Radiology/Pathology interpretation 100% after deductible Paid Same As Network Home Health Care/Private Duty Nursing 100% after deductible 100 visit Calendar Year maximum 80% after deductible 50 visit Calendar Year maximum NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care 100% after deductible 180 day Lifetime maximum Not Covered Bereavement Counseling 2 visit Lifetime maximum Not Covered Ambulance Service 100% after deductible Paid Same As Network Jaw Joint/TMJ 100% after deductible Not Covered Wig After Chemotherapy 100% after deductible $400 Lifetime maximum 80% after deductible $400 Lifetime maximum Physical/Occupational Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Speech & Vision Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Spinal Manipulation/ Chiropractic 100% after deductible 15 visit Calendar Year maximum 80% after deductible 15 visit Calendar Year maximum Mental Disorders/Substance Abuse Paid based on the type of service(s) received.

Preventive Care. Routine Well Adult Preventive Care Your plan pays 100% 60Your plan pays 80% after deductible Includes: office visits Includes coverage of additional services, pap smearsuch as urinalysis, mammogramEKG, gynecological exam, routine physical examination, x- rays, and other laboratory tests, prostate specific antigen test, colonoscopies, sigmoidoscopies and anoscopy, proctosigmoidoscopy, medical tests and other preventive services as required by lawsupplementing the standard Preventive Care benefit. Routine Well Child Care Immunizations Your plan pays 100% 60Your plan pays 100% after deductible Includes: office visitsMammogram, routine physical examinationPAP, laboratory tests, and PSA Tests Your plan pays 100% Your plan pays 80%  Coverage includes the associated Preventive Outpatient Professional Services.  Diagnostic-related services are covered at the same level of benefits as other x-raysray and lab services, immunizationsbased on place of service. Inpatient Inpatient Hospital Facility $200 per admission copay, and other Preventive services as required by law. Flu Shots then your plan pays 100% Paid Same As Network Eye Exam (including refractive exams) $200 per admission deductible, then your plan pays 80% Inpatient Hospital Physician's Visit/Consultation Your plan pays 100% after Copayment Limited to 1 per Calendar Year, unless otherwise required by law Not Covered Organ Transplants Your plan pays 80% after deductible Not Covered Other Medical Inpatient Professional Services  For services performed by Surgeons, Radiologists, Pathologists and Supplies Anesthesiologists Your plan pays 100% Your plan pays 80% after Outpatient Facility Services  Non-surgical treatment procedures are not subject to the facility per visit copay/benefit deductible 60% after deductible Drugs and Products included on the Select Drugs and Products List Require pre-certification and enrollment in the Select Drugs and Products Program Generic Drugs $10 copayment Formulary Brand Name Drugs $20 copayment Nonper facility visit copay, then your plan pays 100% Your plan pays 80% Note: Services where plan deductible applies are noted with a caret (^) Outpatient Professional Services  For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists Your plan pays 100% Your plan pays 80% Short-Formulary Brand Name Drugs $50 copayment Specialty Drugs May be available through the Select Drugs and Products Program Generic Drugs Term Rehabilitation $20 copayment Formulary Brand Name Drugs PCP or $40 copayment Non20 Specialist copay Your plan pays 80% Calendar Year Maximums:  Pulmonary Rehabilitation, Cognitive Therapy, Physical Therapy, Occupational Therapy and Chiropractic Care – 30 days  Cardiac Rehabilitation - Unlimited days  Coverage includes non-Formulary Brand Name Drugs $100 copayment NOTErestorative services Note: Charges for Prescription Drugs obtained through the Prescription Drug Benefit section will not apply Therapy days, provided as part of an approved Home Health Care plan, accumulate to the Calendar Year Deductibleapplicable outpatient short term rehab therapy maximum. Prescription Drug expenses do apply to the Out-of-Pocket Maximum under Medical Benefits section of this Plan. Per Covered Person $2,800 $5,000 Per Family Unit $5,000 $10,000 Amounts applied to the Network Deductible and the Non-Network Deductible do not cross-apply. The Calendar Year deductible is waived for the following Covered Charges: - Network Preventive Care - Flu Shots Per Covered Person $2,800 $6,000 Per Family Unit $5,000 $12,000 The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum: Non-Precertification penalties Amounts over Usual and Reasonable Charge Amounts for products included on the Select Drugs and Products List Room, Board, and Miscellaneous Expenses 100% after deductible 80% after deductible Intensive Care Unit 100% after deductible 80% after deductible Surgical Facilities 100% after deductible 80% after deductible Other Outpatient Services 100% after deductible 80% after deductible Emergency Room Visit 100% after deductible Paid Same As Network Urgent Care Facility 100% after deductible 80% after deductible Skilled Nursing Facility 100% after deductible 180 day Calendar Year Speech Therapy  60 days maximum 80% after deductible 60 day Calendar Year maximum Inpatient visits 100% after deductible 80% after deductible Office visits (including related services billed by the Physician) 100% after deductible 80% after deductible Surgery 100% after deductible 80% after deductible Anesthesia 100% after deductible Paid Same As Network Allergy services 100% after deductible 80% after deductible Diagnostic Testing (X-ray & Lab) 100% after deductible 80% after deductible Independent Laboratory expenses 100% after deductible Paid Same As Network Radiology/Pathology interpretation 100% after deductible Paid Same As Network Home Health Care/Private Duty Nursing 100% after deductible 100 visit Calendar Year maximum 80% after deductible 50 visit Calendar Year maximum NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care 100% after deductible 180 day Lifetime maximum Not Covered Bereavement Counseling 2 visit Lifetime maximum Not Covered Ambulance Service 100% after deductible Paid Same As Network Jaw Joint/TMJ 100% after deductible Not Covered Wig After Chemotherapy 100% after deductible $400 Lifetime maximum 80% after deductible $400 Lifetime maximum Physical/Occupational Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year  Coverage includes non-restorative services $20 PCP or $20 Specialist copay Your plan pays 80% after deductible Limited Home Health Care (includes outpatient private duty nursing subject to 10 visits for each therapy medical necessity)  Unlimited days maximum per Calendar Year Speech & Vision Therapy  16 hour maximum per day Your plan pays 100% after deductible Limited to 20 visits for each therapy Your plan pays 80% Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facility  60 days maximum per Calendar Year Your plan pays 100% Your plan pays 80% after deductible Limited to 10 visits for each therapy Durable Medical Equipment  Unlimited maximum per Calendar Year Spinal Manipulation/ Chiropractic Your plan pays 100% after deductible 15 visit Your plan pays 80% Breast Feeding Equipment and Supplies  Limited to the rental of one breast pump per birth as ordered or prescribed by a physician.  Includes related supplies Your plan pays 100% Your plan pays 80% External Prosthetic Appliances (EPA)  Unlimited maximum per Calendar Year maximum  Includes wigs and foot orthotics Your plan pays 100% Your plan pays 80% after deductible 15 visit Routine Foot Disorders Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary. Acupuncture  Unlimited maximum per Calendar Year $20 PCP or $20 Specialist copay Not covered Routine Eye Exam  Limited to one per calendar year. Excludes refractions. $20 PCP or $20 Specialist copay Your plan pays 80% Note: Services where plan deductible applies are noted with a caret (^) Hearing Exams  Routine Hearing Exams covered to age 18 $20 PCP or $20 Specialist copay Your plan pays 80% Hearing Aid  $1,000 maximum Mental Disordersper Calendar Year  Includes testing and fitting of hearing aid devices covered at PCP or Specialist Office visit level  Coverage through age 12 Your plan pays 100% Your plan pays 80% Lab and X- ray Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 100% Plan pays 80% Advanced Radiology Imaging Plan pays 100% Plan pays 80% Not Applicable Not Applicable Plan pays 100% Plan pays 100% Plan pays 80% Advanced Radiology Imaging (ARI) includes MRI, MRA, CAT Scan, PET Scan, etc. Note: All lab and x-ray services, including ARI, provided at Inpatient Hospital are covered under Inpatient Hospital benefit Emergency Care $75 per visit (copay waived if admitted) Plan pays 100% Plan pays 100% Urgent Care $20 per visit (copay waived if admitted) Plan pays 100% Not Applicable *Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered. Hospice Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Bereavement Counseling Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Note: Services provided as part of Hospice Care Program Benefit Initial Visit to Confirm Pregnancy Global Maternity Fee (All Subsequent Prenatal Visits, Postnatal Visits and Physician's Delivery Charges) Office Visits in Addition to Global Maternity Fee (Performed by OB/Substance Abuse Paid based GYN or Specialist) Delivery - Facility (Inpatient Hospital, Birthing Center) In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Maternity $20 PCP or $20 Specialist copay Plan pays 80% Plan pays 100% Plan pays 80% $20 PCP or $20 Specialist copay Plan pays 80% Covered same as plan's Inpatient Hospital benefit Covered same as plan's Inpatient Hospital benefit Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services Abortion (Elective and non-elective procedures) $20 PCP or $20 Specialist copay Plan pays 80% $200 per admission copay, then plan pays 100% $200 per admission deductible, then plan pays 80% $20 per facility visit copay, then plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Family Planning - Men's Services $20 PCP or $20 Specialist copay Plan pays 80% $200 per admission copay, then plan pays 100% $200 per admission deductible, then plan pays 80% $20 per facility visit copay, then plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Includes surgical services, such as vasectomy (excludes reversals) Family Planning - Women's Services Plan pays 100% Plan pays 80% Plan pays 100% $200 per admission deductible, then plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Includes surgical services, such as tubal ligation (excludes reversals) Contraceptive devices as ordered or prescribed by a physician. Infertility $20 PCP or $20 Specialist copay Plan pays 80% $200 per admission copay, then plan pays 100% $200 per admission deductible, then plan pays 80% $20 per facility visit copay, then plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Infertility covered services: lab and radiology test, counseling, surgical treatment, includes artificial insemination and excludes in-vitro fertilization, GIFT, ZIFT, etc. Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network TMJ, Surgical and Non- Surgical $20 PCP or $20 Specialist copay Plan pays 80% $200 per admission copay, then plan pays 100% $200 per admission deductible, then plan pays 80% $20 per facility visit copay, then plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Services provided on the type of service(s) received.a case-by-case basis. Always excludes appliances & orthodontic treatment. Subject to medical necessity. Unlimited maximum per lifetime Oral Surgery - Impacted Wisdom Teeth $20 PCP or $20 Specialist copay Plan pays 80% $200 per admission copay, then plan pays 100% $200 per admission deductible, then plan pays 80% $20 per facility visit copay, then plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Bariatric Surgery $20 PCP or $20 Specialist copay Plan pays 80% $200 per admission copay, then plan pays 100% $200 per admission deductible, then plan pays 80% $20 per facility visit copay, then plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80% Plan pays 100% Plan pays 80%

Preventive Care. Routine Well Adult Preventive Care Plan pays 100% 60After the plan deductible is met, your plan pays 70% after deductible Includes: office visitsIncludes coverage of additional services, pap smearsuch as urinalysis, mammogramEKG, gynecological exam, routine physical examination, x- rays, and other laboratory tests, prostate specific antigen supplementing the standard Preventive Care benefit when billed as part of office visit. Immunizations Plan pays 100% After the plan deductible is met, your plan pays 70% Mammogram, PAP, and PSA Tests Plan pays 100% Plan pays based on place of service. Coverage includes the associated Preventive Outpatient Professional Services. Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on place of service. Inpatient Hospital Facility Services After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Inpatient Hospital Physician’s Visit/Consultation After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Inpatient Professional Services For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Facility Services After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Professional Services For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Short-Term Rehabilitation - PCP Short-Term Rehabilitation - Specialist After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Contract Year Maximums: Pulmonary Rehabilitation & Cognitive Therapy - Unlimited days Physical Therapy, Speech Therapy, Occupational Therapy and Chiropractic Care – 100 days Limits are not applicable to mental health conditions for Physical, Speech and Occupational Therapies. Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Cardiac Rehabilitation - PCP Cardiac Rehabilitation - Specialist After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Contract Year Maximum: Cardiac Rehabilitation – 36 days Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Home Health Care After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Unlimited days maximum per Contract Year Home Health Aide - 80 days per Contract Year Outpatient Private Duty Nursing $15,000 maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities 120 days maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Durable Medical Equipment Unlimited maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Breast Feeding Equipment and Supplies Limited to the rental of one breast pump per birth as ordered or prescribed by a physician Includes related supplies Your plan pays 100% After the plan deductible is met, your plan pays 70% Routine Hearing Exams After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% One exam per Contract Year Routine Eye Care After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% One exam and refraction every Contract Year External Prosthetic Appliances (EPA) After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Unlimited maximum per Contract Year Routine Foot Disorders Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Hearing Aid After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Includes testing and fitting of hearing aid devices at Physician Office Visit cost share. Wigs One per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Inpatient This benefit applies to the cost of the Infusion Therapy drugs administered in an Inpatient Facility. This benefit does not cover the related Facility or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Facility Services This benefit applies to the cost of the Infusion Therapy drugs administered in an Outpatient Facility. This benefit does not cover the related Facility or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Physician's Office This benefit applies to the cost of targeted Infusion Therapy drugs administered in the Physician’s Office. This benefit does not cover the related Office Visit or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Home This benefit applies to the cost of targeted Infusion Therapy drugs administered in the patient’s home. This benefit does not cover the related Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Note: Services where plan deductible applies are noted with a caret (^). Benefit Physician's Office Independent Lab Emergency Room/ Urgent Care Facility Outpatient Facility In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Laboratory Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Plan pays 90% ^ Plan pays 70% ^ Radiology Plan pays 90% ^ Plan pays 70% ^ Not Applicable Not Applicable Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Plan pays 90% ^ Plan pays 70% ^ Advanced Radiology Imaging Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Not Applicable Not Applicable Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Outpatient Facility Services Covered same as plan's Outpatient Facility Services Advanced Radiology Imaging (ARI) includes MRI, MRA, CAT Scan, PET Scan, etc. Note: All lab and x-ray services, including ARI, provided at Inpatient Hospital are covered under Inpatient Hospital benefit Emergency Care Plan pays 90% ^ Plan pays 90% ^ Plan pays 90% ^ Urgent Care Plan pays 90% ^ Plan pays 90% ^ Not Applicable* *Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered. Hospice Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Bereavement Counseling Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Note: Services provided as part of Hospice Care Program Note: Services where plan deductible applies are noted with a caret (^). Benefit Initial Visit to Confirm Pregnancy Global Maternity Fee (All Subsequent Prenatal Visits, Postnatal Visits and Physician's Delivery Charges) Office Visits in Addition to Global Maternity Fee (Performed by OB/GYN or Specialist) Delivery - Facility (Inpatient Hospital, Birthing Center) In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Maternity Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Covered same as plan's Inpatient Hospital benefit Covered same as plan's Inpatient Hospital benefit Note: Services where plan deductible applies are noted with a caret (^). Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Abortion (Elective and non-elective procedures) Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Family Planning - Men's Services Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Includes surgical services, such as vasectomy Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Family Planning - Women's Services Plan pays 100% Covered same as plan's Physician’s Office Services Plan pays 100% Plan pays 70% ^ Plan pays 100% Plan pays 70% ^ Plan pays 100% Covered same as plan's Inpatient Professional Services Plan pays 100% Covered same as plan's Outpatient Professional Services Includes surgical services, such as tubal ligation Contraceptive devices as ordered or prescribed by a physician. Infertility Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Infertility covered services: lab and radiology test, colonoscopiescounseling, sigmoidoscopies surgical treatment, includes artificial insemination, in-vitro fertilization, GIFT, ZIFT, etc. Unlimited maximum per lifetime TMJ, Surgical and anoscopyNon- Surgical Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Services provided on a case-by-case basis. Always excludes appliances & orthodontic treatment. Subject to medical necessity. Unlimited maximum per lifetime Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Bariatric Surgery Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90%^ Plan pays 70%^ Plan pays 90%^ Plan pays 70%^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Surgeon Charges Lifetime Maximum: Unlimited Treatment of clinically severe obesity, proctosigmoidoscopy, as defined by the body mass index (BMI) is covered. The following are excluded: medical tests and other preventive surgical services as required by lawto alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity. Routine Well Child Care 100% 60% after Note: Services where plan deductible Includes: office visits, routine physical examination, laboratory tests, xapplies are noted with a caret (^). Benefit Inpatient Hospital Facility Inpatient Professional Services Cigna LifeSOURCE Transplant Network ® Facility In-rays, immunizations, and other Preventive services as required by law. Flu Shots 100% Paid Same As Network Eye Exam (including refractive exams) 100% after Copayment Limited to 1 per Calendar Year, unless otherwise required by law Not Covered Organ Transplants 80% after deductible Not Covered Other Medical Services and Supplies 80% after deductible 60% after deductible Drugs and Products included on the Select Drugs and Products List Require pre-certification and enrollment in the Select Drugs and Products Program Generic Drugs $10 copayment Formulary Brand Name Drugs $20 copayment Non-Formulary Brand Name Drugs $50 copayment Specialty Drugs May be available through the Select Drugs and Products Program Generic Drugs $20 copayment Formulary Brand Name Drugs $40 copayment NonLifesource Facility In-Formulary Brand Name Drugs $100 copayment NOTE: Charges for Prescription Drugs obtained through the Prescription Drug Benefit section will not apply to the Calendar Year Deductible. Prescription Drug expenses do apply to the Network Out-of-Pocket Maximum under Medical Benefits section of this Plan. Per Covered Person $2,800 $5,000 Per Family Unit $5,000 $10,000 Amounts applied to the Network Deductible and the Cigna LifeSOURCE Transplant Network ® Facility In-Network Non-Lifesource Facility In-Network Deductible do not cross-apply. The Calendar Year deductible is waived for the following Covered Charges: - Network Preventive Care - Flu Shots Per Covered Person $2,800 $6,000 Per Family Unit $5,000 $12,000 The Plan will pay the designated percentage of Covered Charges until outOut-of-pocket amounts are reached, at which time the Network Organ Transplants Plan will pay pays 100% of the remainder of Plan pays 90% ^ Plan pays 70% ^ Plan pays 100% Covered Charges for the rest of the Calendar same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Travel Maximum - Cigna LifeSOURCE Transplant Network® Facility: In-Network: $15,000 maximum per Transplant Note: Services where plan deductible applies are noted with a caret (^). Mental Health Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Substance Use Disorder Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Note: Services where plan deductible applies are noted with a caret (^). Notes: Unlimited maximum per Contract Year unless stated otherwise. The following charges do not apply toward the Services are paid at 100% after you reach your out-of-pocket maximum: Non-Precertification penalties Amounts over Usual . Inpatient includes Acute Inpatient and Reasonable Charge Amounts for products included on the Select Drugs Residential Treatment. Outpatient - Physician's Office - includes Individual, family and Products List Roomgroup therapy, Boardpsychotherapy, medication management, etc. Outpatient - All Other Services - includes Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy) and Miscellaneous Expenses 100% after deductible 80% after deductible Intensive Care Unit 100% after deductible 80% after deductible Surgical Facilities 100% after deductible 80% after deductible Other Outpatient Services 100% after deductible 80% after deductible Emergency Room Visit 100% after deductible Paid Same As Network Urgent Care Facility 100% after deductible 80% after deductible Skilled Nursing Facility 100% after deductible 180 day Calendar Year maximum 80% after deductible 60 day Calendar Year maximum Inpatient visits 100% after deductible 80% after deductible Office visits (including related services billed by the Physician) 100% after deductible 80% after deductible Surgery 100% after deductible 80% after deductible Anesthesia 100% after deductible Paid Same As Network Allergy services 100% after deductible 80% after deductible Diagnostic Testing (X-ray & Lab) 100% after deductible 80% after deductible Independent Laboratory expenses 100% after deductible Paid Same As Network Radiology/Pathology interpretation 100% after deductible Paid Same As Network Home Health Care/Private Duty Nursing 100% after deductible 100 visit Calendar Year maximum 80% after deductible 50 visit Calendar Year maximum NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care 100% after deductible 180 day Lifetime maximum Not Covered Bereavement Counseling 2 visit Lifetime maximum Not Covered Ambulance Service 100% after deductible Paid Same As Network Jaw Joint/TMJ 100% after deductible Not Covered Wig After Chemotherapy 100% after deductible $400 Lifetime maximum 80% after deductible $400 Lifetime maximum Physical/Occupational Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Speech & Vision Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Spinal Manipulation/ Chiropractic 100% after deductible 15 visit Calendar Year maximum 80% after deductible 15 visit Calendar Year maximum Behavioral Telehealth Consultation, etc. Detox is covered under medical. Mental DisordersHealth/Substance Abuse Paid Use Disorder Utilization Review, Case Management and Programs Cigna Total Behavioral Health - Inpatient and Outpatient Management Inpatient utilization review and case management Outpatient utilization review and case management Partial Hospitalization Intensive outpatient programs Changing Lives by Integrating Mind and Body Program Lifestyle Management Programs: Stress Management, Tobacco Cessation and Weight Management. Pharmacy benefits not provided by Cigna Case Management Coordinated by Cigna HealthCare. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost effective care while maximizing the patient's quality of life. Comprehensive Oncology Program Care Management outreach Case Management Included eVisits Relay Health provides an online consultation service, or “eVisit,” with doctors. The eVisit guides patients through an interactive interview that delivers to doctors the information they need to respond to non-urgent conditions. Individuals pay a predetermined copay or coinsurance based on their benefit plan design. After the type of service(s) received.eVisit is completed, a claim is automatically submitted to Cigna for reimbursement. Health Advisor - A Support for healthy and at-risk individuals to help them stay healthy Health Assessments Health and Wellness Coaching Gaps in Care Coaching Treatment Decision Support Educate and Refer Included

Preventive Care. Routine Well Adult Care 100% 6070% after deductible Includes: office visits, pap smear, mammogram, prostate screening, gynecological exam, routine physical examination, x- x-rays, laboratory tests, prostate specific antigen testhearing tests, vision tests, immunizations/flu shots, colonoscopies, sigmoidoscopies and anoscopybone density scans, proctosigmoidoscopy, medical stress tests and other preventive services as required by lawsigmoidoscopies. NETWORK PROVIDERS NON-NETWORK PROVIDERS Routine Well Child Care 100% 6070% after deductible Includes: office visits, routine physical examination, laboratory tests, x-rays, immunizationshearing tests, vision tests and other Preventive services as required by lawimmunizations through age to the end of the calendar year in which the dependent turns 19. Flu Shots 100% Paid Same As Network Eye Exam (including refractive exams) 100% after Copayment Limited to 1 per Calendar Year, unless otherwise required by law Not Covered Organ Transplants 8090% after deductible Not Covered Other Medical Services and Supplies 8050% after deductible 60% after deductible Drugs and Products included on the Select Drugs and Products List Require pre-certification and enrollment in the Select Drugs and Products Program Generic Drugs Maximum Benefit of $10 copayment Formulary Brand Name Drugs $20 copayment Non-Formulary Brand Name Drugs $50 copayment Specialty Drugs May be available through the Select Drugs and Products Program Generic Drugs $20 copayment Formulary Brand Name Drugs $40 copayment Non-Formulary Brand Name Drugs $100 copayment NOTE: Charges 30,000 for Prescription Drugs obtained through the Prescription Drug Benefit section will not apply to the Calendar Year Deductibleunrelated donor searches for bone marrow/stem cell transplants per transplant per Covered Person. Prescription Drug expenses do apply to the Out-of-Pocket Maximum under Medical Benefits section of this Plan. Per Covered Person $2,800 $5,000 Per Family Unit $5,000 $10,000 Amounts applied to the Network Deductible and the Non-Network Deductible do not cross-apply. The Calendar Year deductible is waived for the following Covered Charges: - Network Preventive Care - Flu Shots Per Covered Person $2,800 $6,000 Per Family Unit $5,000 $12,000 The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum: Non-Precertification penalties Amounts over Usual and Reasonable Charge Amounts for products included on the Select Drugs and Products List Room, Board, and Miscellaneous Expenses 100% after deductible 80% after deductible Intensive Care Unit 100% after deductible 80% after deductible Surgical Facilities 100% after deductible 80% after deductible Other Outpatient Services 100% after deductible 80% after deductible Emergency Room Visit 100% after deductible Paid Same As Network Urgent Care Facility 100% after deductible 80% after deductible Skilled Nursing Facility 100% after deductible 180 day Calendar Year maximum 80% after deductible 60 day Calendar Year maximum Inpatient visits 100% after deductible 80% after deductible Office visits Temporomandibular Joint (including related services billed by the PhysicianTMJ) 100% after deductible 80% after deductible Surgery 100% after deductible 80% after deductible Anesthesia 100% after deductible Paid Same As Network Allergy services 100% after deductible 80% after deductible Diagnostic Testing (X-ray & Lab) 100% after deductible 80% after deductible Independent Laboratory expenses 100% after deductible Paid Same As Network Radiology/Pathology interpretation 100% after deductible Paid Same As Network Home Health Care/Private Duty Nursing 100% after deductible 100 visit Calendar Year maximum 80% after deductible 50 visit Calendar Year maximum NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care 100% after deductible 180 day Lifetime maximum Not Covered Bereavement Counseling 2 visit Lifetime maximum Not Covered Ambulance Service 100% after deductible Paid Same As Network Jaw Joint/TMJ 100% after deductible Not Covered Wig After Chemotherapy 100% after deductible $400 Lifetime maximum 80% after deductible $400 Lifetime maximum Physical/Occupational Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Speech & Vision Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Spinal Manipulation/ Chiropractic 100% after deductible 15 visit Calendar Year maximum 80% after deductible 15 visit Calendar Year maximum Mental Disorders/Substance Abuse Paid based on the type of service(s) received. Other Medical Services and Supplies 90% after deductible 70% after deductible Generic Drugs $10 copayment $30 copayment Preferred Brand Name Drugs $25 copayment $30 copayment Non-Preferred Brand Name Drugs $40 copayment $30 copayment Generic Drugs $20 copayment Not Covered Preferred Brand Name Drugs $40 copayment Not Covered Non-Preferred Brand Name Drugs $60 copayment Not Covered If you obtain services from a Non-Network Pharmacy, Caremark will provide 50% of the Prescription Drug, after the Prescription Drug Copayment, as indicated in the above Schedule. You must pay the full amount of the ▇▇▇▇ for the Prescription Drug at the time of purchase. Then you must file a Standard Claim Form, which can be obtained from Caremark, and payment will be made directly to you. You may be responsible for any amount in excess of the Prescription Drug Covered Charges. This is only a partial list of benefits. The contract or certificate with the Board will contain the complete listing of covered services.

Preventive Care. Routine Well Adult Preventive Care Plan pays 100% 60After the plan deductible is met, your plan pays 70% after deductible Includes: office visitsIncludes coverage of additional services, pap smearsuch as urinalysis, mammogramEKG, gynecological exam, routine physical examination, x- rays, and other laboratory tests, prostate specific antigen test, colonoscopies, sigmoidoscopies and anoscopy, proctosigmoidoscopy, medical tests and other preventive services supplementing the standard Preventive Care benefit when billed as required by lawpart of office visit. Routine Well Child Care Immunizations Plan pays 100% 60After the plan deductible is met, your plan pays 70% after deductible Includes: office visitsMammogram, routine physical examinationPAP, laboratory tests, and PSA Tests Plan pays 100% Plan pays based on Place of Service. Coverage includes the associated Preventive Outpatient Professional Services.Diagnostic-related services are covered at the same level of benefits as other x-raysray and lab services, immunizationsbased on Place of Service. Inpatient Hospital Facility Services After the plan deductible is met, and other Preventive services as required by law. Flu Shots 100yourplan pays 90% Paid Same As Network Eye Exam (including refractive exams) 100After the plan deductible is met,your plan pays 70% after Copayment Semi-Private Room: In-Network: Limited to 1 per Calendar Year, unless otherwise required by law Not Covered Organ Transplants 80% after deductible Not Covered Other Medical Services and Supplies 80% after deductible 60% after deductible Drugs and Products included on the Select Drugs and Products List Require presemi-certification and enrollment in the Select Drugs and Products Program Generic Drugs $10 copayment Formulary Brand Name Drugs $20 copayment Non-Formulary Brand Name Drugs $50 copayment Specialty Drugs May be available through the Select Drugs and Products Program Generic Drugs $20 copayment Formulary Brand Name Drugs $40 copayment Non-Formulary Brand Name Drugs $100 copayment NOTE: Charges for Prescription Drugs obtained through the Prescription Drug Benefit section will not apply to the Calendar Year Deductible. Prescription Drug expenses do apply to the private negotiated rate / Out-of-Pocket Maximum under Medical Benefits section of this Plan. Per Covered Person $2,800 $5,000 Per Family Unit $5,000 $10,000 Amounts applied Network: Limited to semi-private ratePrivate Room: In-Network: Limited to the Network Deductible and the Nonsemi-Network Deductible do not cross-apply. The Calendar Year deductible is waived for the following Covered Charges: - Network Preventive Care - Flu Shots Per Covered Person $2,800 $6,000 Per Family Unit $5,000 $12,000 The Plan will pay the designated percentage of Covered Charges until outprivate negotiated rate / Out-of-pocket amounts Network: Limited to semi-private rateSpecial Care Units (Intensive Care Unit (ICU), Critical Care Unit (CCU)): In-Network: Limited to the negotiated rate / Out-of-Network: Limited to ICU/CCU daily room rate Inpatient Hospital Physician’s Visit/Consultation After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Inpatient Professional ServicesFor services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Facility Services After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Outpatient Professional ServicesFor services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Short-Term Rehabilitation - PCP Short-Term Rehabilitation - Specialist After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Contract Year Maximums:Pulmonary Rehabilitation & Cognitive Therapy - Unlimited daysPhysical Therapy, Speech Therapy, Occupational Therapy and Chiropractic Care – 100 daysLimits are reachednot applicable to mental health conditions for Physical, at which time Speech and Occupational Therapies. Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the Plan will pay applicable outpatient short term rehab therapy maximum. Cardiac Rehabilitation - PCP Cardiac Rehabilitation - Specialist After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Contract Year Maximum:Cardiac Rehabilitation – 36 days Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Home Health Care After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Unlimited days maximum per Contract Year Home Health Aide - 80 days per Contract Year Outpatient Private Duty Nursing$15,000 maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities120 days maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Durable Medical EquipmentUnlimited maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Breast Feeding Equipment and SuppliesLimited to the rental of one breast pump per birth as ordered or prescribed by a physician Includes related supplies Your plan pays 100% After the plan deductible is met, your plan pays 70% External Prosthetic Appliances (EPA) After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Unlimited maximum per Contract Year Routine Foot Disorders Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Foot Orthotics After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Excludes surgical shoes or boots Once per Member per Contract Year Routine Eye Care After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% One exam and refraction every Contract Year Eyeglasses for Accidental Injury After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% One pair per lifetime Routine Hearing Exams After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% One exam per Contract Year AcupunctureUnlimited days maximum per Contract Year Coverage for medical diagnosis only After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Hearing Aid After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Includes testing and fitting of hearing aid devices at Physician Office Visit cost share. WigsOne per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Benefit In-Network Out-of-Network InpatientThis benefit applies to the cost of the remainder of Covered Charges for Infusion Therapy drugs administered in an Inpatient Facility. This benefit does not cover the rest related Facility or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Facility ServicesThis benefit applies to the cost of the Calendar Year unless stated otherwiseInfusion Therapy drugs administered in an Outpatient Facility. This benefit does not cover the related Facility or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Physician's OfficeThis benefit applies to the cost of targeted Infusion Therapy drugs administered in the Physician’s Office. This benefit does not cover therelated Office Visit or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% HomeThis benefit applies to the cost of targeted Infusion Therapy drugs administered in the patient’s home. This benefit does not cover the relatedProfessional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Note: Services where plan deductible applies are noted with a caret (^). Benefit Physician's Office Independent Lab Emergency Room/ Urgent Care Facility Outpatient Facility In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Laboratory Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90%^ Plan pays 70%^ Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Plan pays 90% ^ Plan pays 70% ^ Radiology Plan pays 90%^ Plan pays 70%^ Not Applicable Not Applicable Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Plan pays 90% ^ Plan pays 70% ^ Note: Services where plan deductible applies are noted with a caret (^). Benefit Physician's Office Independent Lab Emergency Room/ Urgent Care Facility Outpatient Facility In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Advanced Radiology Imaging Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Not Applicable Not Applicable Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Outpatient Facility Services Covered same as plan's Outpatient Facility Services Advanced Radiology Imaging (ARI) includes MRI, MRA, CAT Scan, PET Scan, etc.Note: All lab and x-ray services, including ARI, provided at Inpatient Hospital are covered under Inpatient Hospital benefit EmergencyCare Plan pays 90% ^ Plan pays 90% ^ Plan pays 90% ^ Urgent Care Plan pays 90% ^ Plan pays 90% ^ Not Applicable* *Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered. Hospice Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ BereavementCounseling Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Note: Services provided as part of Hospice Care Program Note: Services where plan deductible applies are noted with a caret (^). Benefit Visit to Confirm Pregnancy Global Maternity Fee (All Subsequent Prenatal Visits, Postnatal Visits and Physician's Delivery Charges) Office Visits in Addition to Global Maternity Fee (Performed by OB/GYN or Specialist) Delivery - Facility (Inpatient Hospital, Birthing Center) In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Maternity Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90%^ Plan pays 70%^ Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Covered same as plan's Inpatient Hospital benefit Covered same as plan's Inpatient Hospital benefit Note: Services where plan deductible applies are noted with a caret (^). Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Abortion (Elective and non-elective procedures) Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Family Planning - Men's Services Covered same as plan's Physician’sOffice Services Covered same as plan's Physician’sOffice Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Includes surgical services, such as vasectomy Family Planning - Women's Services Plan pays 100% Covered same as plan's Physician’sOffice Services Plan pays 100% Plan pays 70% ^ Plan pays 100% Plan pays 70% ^ Plan pays 100% Covered same as plan's Inpatient Professional Services Plan pays 100% Covered same as plan's Outpatient Professional Services Includes surgical services, such as tubal ligationContraceptive devices as ordered or prescribed by a physician. Infertility Covered same as plan's Physician’s OfficeServices Covered same as plan's Physician’s OfficeServices Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient ProfessionalServices Infertility covered services: lab and radiology test, counseling, surgical treatment, includes artificial insemination, in-vitro fertilization, GIFT, ZIFT, etc. Unlimited maximum per lifetime TMJ, Surgical and Non- Surgical Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Services provided on a case-by-case basis. Always excludes appliances & orthodontic treatment. Subject to medical necessity. Unlimited maximum per lifetime Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Bariatric Surgery Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90%^ Plan pays 70%^ Plan pays 90%^ Plan pays 70%^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Profession al Services Surgeon Charges Lifetime Maximum: Unlimited Treatment of clinically severe obesity, as defined by the body mass index (BMI) is covered. The following charges do not apply toward are excluded: medical and surgical services to alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity. Note: Services where plan deductible applies are noted with a caret (^). Benefit Inpatient Hospital Facility Inpatient Professional Services Cigna LifeSOURCE Transplant Network ® Facility In-Network Non-Lifesource Facility In-Network Out-of-Network Cigna LifeSOURCE Transplant Network ® Facility In-Network Non-Lifesource Facility In-Network Out-of-Network Organ Transplants Plan pays 100% ^ Plan pays 90% ^ Plan pays 70% ^ Plan pays 100% ^ Covered same asplan's Inpatient Professional Services Covered same asplan's Inpatient Professional Travel Maximum - Cigna LifeSOURCE Transplant Network® Facility: In-Network: $15,000 maximum per Transplant Note: Services where plan deductible applies are noted with a caret (^). Mental Health Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Substance Use Disorder Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Note: Services where plan deductible applies are noted with a caret (^). Notes:Unlimited maximum per Contract YearServices are paid at 100% after you reach your out-of-pocket maximum: Non-Precertification penalties Amounts over Usual . Inpatient includes Acute Inpatient and Reasonable Charge Amounts for products included on the Select Drugs Residential Treatment. Outpatient - Physician's Office - includes Individual, family and Products List Roomgroup therapy, Boardpsychotherapy, medication management, etc.Outpatient - All Other Services - includes Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy) and Miscellaneous Expenses 100% after deductible 80% after deductible Intensive Care Unit 100% after deductible 80% after deductible Surgical Facilities 100% after deductible 80% after deductible Other Outpatient Services 100% after deductible 80% after deductible Emergency Room Visit 100% after deductible Paid Same As Network Urgent Care Facility 100% after deductible 80% after deductible Skilled Nursing Facility 100% after deductible 180 day Calendar Year maximum 80% after deductible 60 day Calendar Year maximum Inpatient visits 100% after deductible 80% after deductible Office visits (including related services billed by the Physician) 100% after deductible 80% after deductible Surgery 100% after deductible 80% after deductible Anesthesia 100% after deductible Paid Same As Network Allergy services 100% after deductible 80% after deductible Diagnostic Testing (X-ray & Lab) 100% after deductible 80% after deductible Independent Laboratory expenses 100% after deductible Paid Same As Network Radiology/Pathology interpretation 100% after deductible Paid Same As Network Home Health Care/Private Duty Nursing 100% after deductible 100 visit Calendar Year maximum 80% after deductible 50 visit Calendar Year maximum NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care 100% after deductible 180 day Lifetime maximum Not Covered Bereavement Counseling 2 visit Lifetime maximum Not Covered Ambulance Service 100% after deductible Paid Same As Network Jaw Joint/TMJ 100% after deductible Not Covered Wig After Chemotherapy 100% after deductible $400 Lifetime maximum 80% after deductible $400 Lifetime maximum Physical/Occupational Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Speech & Vision Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Spinal Manipulation/ Chiropractic 100% after deductible 15 visit Calendar Year maximum 80% after deductible 15 visit Calendar Year maximum Behavioral Telehealth Consultation, etc. Detox is covered under medical. Mental DisordersHealth/Substance Abuse Paid based on Use Disorder Utilization Review, Case Management and ProgramsCigna Total Behavioral Health - Inpatient and Outpatient Management Inpatient utilization review and case management Outpatient utilization review and case management Partial Hospitalization Intensive outpatient programsChanging Lives by Integrating Mind and Body ProgramLifestyle Management Programs: Stress Management, Tobacco Cessation and Weight Management. Pharmacy benefits not provided by Cigna Case ManagementCoordinated by Cigna HealthCare. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost effective care while maximizing the type patient's quality of service(s) received.life. Comprehensive Oncology ProgramCare Management outreach Case Management Included Vision TherapyOrthoptic Training Covered eVisitsRelay Health provides an online consultation service, or “eVisit,” with doctors. The eVisit guides patients through an interactive interview that delivers to doctors the information they need to respond to non-urgent conditions. Individuals pay a predetermined copay or coinsuran

Preventive Care. Routine Well Adult Preventive Care Plan pays 100% 60After the plan deductible is met, your plan pays 70% after deductible Includes: office visitsc Includes coverage of additional services, pap smearsuch as urinalysis, mammogramEKG, gynecological exam, routine physical examination, x- rays, and other laboratory tests, prostate specific antigen supplementing the standard Preventive Care benefit when billed as part of office visit. Immunizations Plan pays 100% After the plan deductible is met, your plan pays 70% Mammogram, PAP, and PSA Tests Plan pays 100% Plan pays based on place of service. c Coverage includes the associated Preventive Outpatient Professional Services. c Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on place of service. Inpatient Hospital Facility Services After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Inpatient Hospital Physician’s Visit/Consultation After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Inpatient Professional Services c For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Facility Services After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Professional Services c For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Short-Term Rehabilitation - PCP Short-Term Rehabilitation - Specialist After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Contract Year Maximums: c Pulmonary Rehabilitation & Cognitive Therapy - Unlimited days c Physical Therapy, Speech Therapy, Occupational Therapy and Chiropractic Care – 100 days c Limits are not applicable to mental health conditions for Physical, Speech and Occupational Therapies. Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Cardiac Rehabilitation - PCP Cardiac Rehabilitation - Specialist After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Contract Year Maximum: c Cardiac Rehabilitation – 36 days Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Home Health Care After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% c Unlimited days maximum per Contract Year Home Health Aide - 80 days per Contract Year Outpatient Private Duty Nursing c $15,000 maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities c 120 days maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Durable Medical Equipment c Unlimited maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Breast Feeding Equipment and Supplies c Limited to the rental of one breast pump per birth as ordered or prescribed by a physician c Includes related supplies Your plan pays 100% After the plan deductible is met, your plan pays 70% Routine Hearing Exams After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% c One exam per Contract Year Routine Eye Care After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% c One exam and refraction every Contract Year External Prosthetic Appliances (EPA) After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% c Unlimited maximum per Contract Year Routine Foot Disorders Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Hearing Aid After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% c Includes testing and fitting of hearing aid devices at Physician Office Visit cost share. Wigs c One per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Inpatient c This benefit applies to the cost of the Infusion Therapy drugs administered in an Inpatient Facility. This benefit does not cover the related Facility or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Facility Services c This benefit applies to the cost of the Infusion Therapy drugs administered in an Outpatient Facility. This benefit does not cover the related Facility or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Physician's Office c This benefit applies to the cost of targeted Infusion Therapy drugs administered in the Physician’s Office. This benefit does not cover the related Office Visit or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Home c This benefit applies to the cost of targeted Infusion Therapy drugs administered in the patient’s home. This benefit does not cover the related Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Note: Services where plan deductible applies are noted with a caret (^). Benefit Physician's Office Independent Lab Emergency Room/ Urgent Care Facility Outpatient Facility In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Laboratory Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Plan pays 90% ^ Plan pays 70% ^ Radiology Plan pays 90% ^ Plan pays 70% ^ Not Applicable Not Applicable Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Plan pays 90% ^ Plan pays 70% ^ Advanced Radiology Imaging Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Not Applicable Not Applicable Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Outpatient Facility Services Covered same as plan's Outpatient Facility Services Advanced Radiology Imaging (ARI) includes MRI, MRA, CAT Scan, PET Scan, etc. Note: All lab and x-ray services, including ARI, provided at Inpatient Hospital are covered under Inpatient Hospital benefit Emergency Care Plan pays 90% ^ Plan pays 90% ^ Plan pays 90% ^ Urgent Care Plan pays 90% ^ Plan pays 90% ^ Not Applicable* *Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered. Hospice Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Bereavement Counseling Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Note: Services provided as part of Hospice Care Program Note: Services where plan deductible applies are noted with a caret (^). Benefit Initial Visit to Confirm Pregnancy Global Maternity Fee (All Subsequent Prenatal Visits, Postnatal Visits and Physician's Delivery Charges) Office Visits in Addition to Global Maternity Fee (Performed by OB/GYN or Specialist) Delivery - Facility (Inpatient Hospital, Birthing Center) In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Maternity Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Covered same as plan's Inpatient Hospital benefit Covered same as plan's Inpatient Hospital benefit Note: Services where plan deductible applies are noted with a caret (^). Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Abortion (Elective and non-elective procedures) Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Family Planning - Men's Services Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Includes surgical services, such as vasectomy Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Family Planning - Women's Services Plan pays 100% Covered same as plan's Physician’s Office Services Plan pays 100% Plan pays 70% ^ Plan pays 100% Plan pays 70% ^ Plan pays 100% Covered same as plan's Inpatient Professional Services Plan pays 100% Covered same as plan's Outpatient Professional Services Includes surgical services, such as tubal ligation Contraceptive devices as ordered or prescribed by a physician. Infertility Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Infertility covered services: lab and radiology test, colonoscopiescounseling, sigmoidoscopies surgical treatment, includes artificial insemination, in-vitro fertilization, GIFT, ZIFT, etc. Unlimited maximum per lifetime TMJ, Surgical and anoscopyNon- Surgical Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Services provided on a case-by-case basis. Always excludes appliances & orthodontic treatment. Subject to medical necessity. Unlimited maximum per lifetime Benefit Physician's Office Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Bariatric Surgery Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90%^ Plan pays 70%^ Plan pays 90%^ Plan pays 70%^ Covered same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services Covered same as plan's Outpatient Professional Services Covered same as plan's Outpatient Professional Services Surgeon Charges Lifetime Maximum: Unlimited Treatment of clinically severe obesity, proctosigmoidoscopy, as defined by the body mass index (BMI) is covered. The following are excluded: c medical tests and other preventive surgical services as required by lawto alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity. Routine Well Child Care 100% 60% after Note: Services where plan deductible Includes: office visits, routine physical examination, laboratory tests, xapplies are noted with a caret (^). Benefit Inpatient Hospital Facility Inpatient Professional Services Cigna LifeSOURCE Transplant Network ® Facility In-rays, immunizations, and other Preventive services as required by law. Flu Shots 100% Paid Same As Network Eye Exam (including refractive exams) 100% after Copayment Limited to 1 per Calendar Year, unless otherwise required by law Not Covered Organ Transplants 80% after deductible Not Covered Other Medical Services and Supplies 80% after deductible 60% after deductible Drugs and Products included on the Select Drugs and Products List Require pre-certification and enrollment in the Select Drugs and Products Program Generic Drugs $10 copayment Formulary Brand Name Drugs $20 copayment Non-Formulary Brand Name Drugs $50 copayment Specialty Drugs May be available through the Select Drugs and Products Program Generic Drugs $20 copayment Formulary Brand Name Drugs $40 copayment NonLifesource Facility In-Formulary Brand Name Drugs $100 copayment NOTE: Charges for Prescription Drugs obtained through the Prescription Drug Benefit section will not apply to the Calendar Year Deductible. Prescription Drug expenses do apply to the Network Out-of-Pocket Maximum under Medical Benefits section of this Plan. Per Covered Person $2,800 $5,000 Per Family Unit $5,000 $10,000 Amounts applied to the Network Deductible and the Cigna LifeSOURCE Transplant Network ® Facility In-Network Non-Lifesource Facility In-Network Deductible do not cross-apply. The Calendar Year deductible is waived for the following Covered Charges: - Network Preventive Care - Flu Shots Per Covered Person $2,800 $6,000 Per Family Unit $5,000 $12,000 The Plan will pay the designated percentage of Covered Charges until outOut-of-pocket amounts are reached, at which time the Network Organ Transplants Plan will pay pays 100% of the remainder of Plan pays 90% ^ Plan pays 70% ^ Plan pays 100% Covered Charges for the rest of the Calendar same as plan's Inpatient Professional Services Covered same as plan's Inpatient Professional Services c Travel Maximum - Cigna LifeSOURCE Transplant Network® Facility: In-Network: $15,000 maximum per Transplant Note: Services where plan deductible applies are noted with a caret (^). Mental Health Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Substance Use Disorder Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Plan pays 90% ^ Plan pays 70% ^ Note: Services where plan deductible applies are noted with a caret (^). Notes: c Unlimited maximum per Contract Year unless stated otherwise. The following charges do not apply toward the c Services are paid at 100% after you reach your out-of-pocket maximum: Non-Precertification penalties Amounts over Usual . c Inpatient includes Acute Inpatient and Reasonable Charge Amounts for products included on the Select Drugs Residential Treatment. c Outpatient - Physician's Office - includes Individual, family and Products List Roomgroup therapy, Boardpsychotherapy, medication management, etc. c Outpatient - All Other Services - includes Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy) and Miscellaneous Expenses 100% after deductible 80% after deductible Intensive Care Unit 100% after deductible 80% after deductible Surgical Facilities 100% after deductible 80% after deductible Other Outpatient Services 100% after deductible 80% after deductible Emergency Room Visit 100% after deductible Paid Same As Network Urgent Care Facility 100% after deductible 80% after deductible Skilled Nursing Facility 100% after deductible 180 day Calendar Year maximum 80% after deductible 60 day Calendar Year maximum Inpatient visits 100% after deductible 80% after deductible Office visits (including related services billed by the Physician) 100% after deductible 80% after deductible Surgery 100% after deductible 80% after deductible Anesthesia 100% after deductible Paid Same As Network Allergy services 100% after deductible 80% after deductible Diagnostic Testing (X-ray & Lab) 100% after deductible 80% after deductible Independent Laboratory expenses 100% after deductible Paid Same As Network Radiology/Pathology interpretation 100% after deductible Paid Same As Network Home Health Care/Private Duty Nursing 100% after deductible 100 visit Calendar Year maximum 80% after deductible 50 visit Calendar Year maximum NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care 100% after deductible 180 day Lifetime maximum Not Covered Bereavement Counseling 2 visit Lifetime maximum Not Covered Ambulance Service 100% after deductible Paid Same As Network Jaw Joint/TMJ 100% after deductible Not Covered Wig After Chemotherapy 100% after deductible $400 Lifetime maximum 80% after deductible $400 Lifetime maximum Physical/Occupational Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Speech & Vision Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Spinal Manipulation/ Chiropractic 100% after deductible 15 visit Calendar Year maximum 80% after deductible 15 visit Calendar Year maximum Behavioral Telehealth Consultation, etc. c Detox is covered under medical. Mental DisordersHealth/Substance Abuse Paid Use Disorder Utilization Review, Case Management and Programs Cigna Total Behavioral Health - Inpatient and Outpatient Management c Inpatient utilization review and case management c Outpatient utilization review and case management c Partial Hospitalization c Intensive outpatient programs c Changing Lives by Integrating Mind and Body Program c Lifestyle Management Programs: Stress Management, Tobacco Cessation and Weight Management. Pharmacy benefits not provided by Cigna Case Management Coordinated by Cigna HealthCare. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost effective care while maximizing the patient's quality of life. Comprehensive Oncology Program c Care Management outreach c Case Management Included eVisits Relay Health provides an online consultation service, or “eVisit,” with doctors. The eVisit guides patients through an interactive interview that delivers to doctors the information they need to respond to non-urgent conditions. Individuals pay a predetermined copay or coinsurance based on their benefit plan design. After the type of service(s) received.eVisit is completed, a claim is automatically submitted to ▇▇▇▇▇ for reimbursement. Health Advisor - A Support for healthy and at-risk individuals to help them stay healthy c Health Assessments c Health and Wellness Coaching c Gaps in Care Coaching c Treatment Decision Support c Educate and Refer Included

Preventive Care. Routine Mammograms Pap Tests Well Adult Baby Care - $15 Co-payment Per Visit, then 100% 60Coverage Up to Allowance 30 units (1 month) supply at $7 co-pay for generic drugs, at $25 co-pay for brand name drugs on preferred list, and at $40 co-pay for brand name drugs on non-preferred or specialty lists; 3 co-pay amounts for 100 units (3 months) supply of mail order drugs; 1 co-pay amount for 100 units (3 months) supply at network pharmacies; $7 generic/$25 brand name/$40 non-preferred or specialty per month supply for submitted injectables at network pharmacies; 20% after deductible Includesco-pay for oral and injectable drugs; specialty drugs purchased outside of network specialty pharmacies covered at 50% co-pay (20% co-pay for infertility drugs – per State Mandate); drugs purchased at non-network pharmacies not covered (except for specialty drugs noted above); drugs for cosmetic not covered; quantity limits for certain conditions (less than 30 days) for certain medications (i.e. migraine medications) may apply, when clinically appropriate; dosage forms for certain drugs may apply -- dosage forms designed to achieve physician’s prescription order while dispensing medication in cost-effective manner (eg. 2 twenty- milligram tablets dispensed instead of 1 higher-priced 40-milligram tablet of same medication) Student Coverage to Age 26 No Lifetime Maximum 80% Coverage for Outpatient Labs and X-Rays from a Hospital Non-Network Provider Mandatory Organ Transplant Coverage: office visits100% coverage for eligible costs associated with kidney, pap smearcornea, mammogramallogenic bone marrow, gynecological examheart, routine physical examinationlung, x- raysliver, laboratory tests, prostate specific antigen test, colonoscopies, sigmoidoscopies pancreas and anoscopy, proctosigmoidoscopy, medical tests and small intestine transplants. Radiation Therapy Services Paid in Full $200 Deductible Per Person (3 Per Family Maximum) Per Calyr for Services Rendered by RI Non-Network Providers or other preventive services as required by lawplans Non-Network PPO Providers Managed Benefits Program: Authorization is obtained from providers who participate directly with the healthcare carrier; members responsible for obtaining pre-authorization when using the health care carrier’s PPO providers who do not participate directly with the healthcare carrier or from non-network providers. Routine Well Child Care 100% 60% after deductible IncludesEye Exams: office visits, $15 co-payment – one routine physical examination, laboratory tests, xexam per year at network providers (medically necessary exams as needed); reimbursed at the health care carrier’s allowance minus a $15 co-rays, immunizations, and other Preventive services as required by law. Flu Shots 100% Paid Same As Network Eye Exam (including refractive exams) 100% after Copayment Limited to 1 per Calendar Year, unless otherwise required by law Not Covered Organ Transplants payment at non-participating optometrists/ophthalmologists; 80% after deductible Not Covered Other Medical Services for non-participating routine exams only Eyeglasses and Supplies Contact Lenses: reimbursement up to a maximum of $100 for one prescription eyewear purchase per calendar year Inpatient Chemical Dependency: Detox: up to 5 admissions or 30 days in any calendar year, whichever comes first Rehab: hospital or community residential care services for chemical dependency treatment covered up to 30 days in any calendar year Outpatient Mental Health: up to 30 visits per member, per calendar year (medication visits are unlimited) Outpatient Chemical Dependency: limited to 30 hours per member, per calendar year for facility-based or office-based counseling Physical, Speech & Occupational Therapy - Outpatient : 100% coverage after a hospital stay in the outpatient hospital department; 80% after deductible 60% after deductible Drugs and Products included on the Select Drugs and Products List Require pre-certification and enrollment coverage in the Select Drugs and Products Program Generic Drugs $10 copayment Formulary Brand Name Drugs $20 copayment Non-Formulary Brand Name Drugs $50 copayment Specialty Drugs May be available through the Select Drugs and Products Program Generic Drugs $20 copayment Formulary Brand Name Drugs $40 copayment Non-Formulary Brand Name Drugs $100 copayment NOTE: Charges for Prescription Drugs obtained through the Prescription Drug Benefit section will not apply to the Calendar Year Deductible. Prescription Drug expenses do apply to the Out-of-Pocket Maximum under Medical Benefits section of this Plan. Per Covered Person $2,800 $5,000 Per Family Unit $5,000 $10,000 Amounts applied to the Network Deductible and the Non-Network Deductible do not cross-apply. The Calendar Year deductible is waived for the following Covered Charges: - Network Preventive Care - Flu Shots Per Covered Person $2,800 $6,000 Per Family Unit $5,000 $12,000 The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum: Non-Precertification penalties Amounts over Usual and Reasonable Charge Amounts for products included on the Select Drugs and Products List Room, Board, and Miscellaneous Expenses 100% after deductible 80% after deductible Intensive Care Unit 100% after deductible 80% after deductible Surgical Facilities 100% after deductible 80% after deductible Other Outpatient Services 100% after deductible 80% after deductible Emergency Room Visit 100% after deductible Paid Same As Network Urgent Care Facility 100% after deductible 80% after deductible Skilled Nursing Facility 100% after deductible 180 day Calendar Year maximum 80% after deductible 60 day Calendar Year maximum Inpatient visits 100% after deductible 80% after deductible Office visits (including related services billed by the Physician) 100% after deductible 80% after deductible Surgery 100% after deductible 80% after deductible Anesthesia 100% after deductible Paid Same As Network Allergy services 100% after deductible 80% after deductible Diagnostic Testing (X-ray & Lab) 100% after deductible 80% after deductible Independent Laboratory expenses 100% after deductible Paid Same As Network Radiology/Pathology interpretation 100% after deductible Paid Same As Network Home Health Care/a provider’s office Private Duty Nursing 100% after deductible 100 visit Calendar Year maximum & Ambulance: 80% after deductible 50 visit Calendar Year maximum NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care 100% after deductible 180 day Lifetime maximum Not Covered Bereavement Counseling 2 visit Lifetime maximum Not Covered Ambulance Service 100% after deductible Paid Same As Network Jaw Joint/TMJ 100% after deductible Not Covered Wig After Chemotherapy 100% after deductible $400 Lifetime maximum 80% after deductible $400 Lifetime maximum Physical/Occupational Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Speech & Vision Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Spinal Manipulation/ Chiropractic 100% after deductible 15 visit Calendar Year maximum 80% after deductible 15 visit Calendar Year maximum Mental Disorders/Substance Abuse Paid coverage Municipal Ground Ambulance: reimbursement based on the type healthcare carrier’s allowance and subject to any applicable co-payment, co- ins and/or deductibles; members responsible for balances over the healthcare carrier’s allowance when using non-participating municipal ambulance companies Air and Water Ambulance: reimbursement based on the healthcare carrier’s allowance and subject to any applicable co-payment, co-insurance, and/or deductibles; maximum benefit of service(s$3,000 per occurrence applies; members responsible for any charges exceeding $3,000 maximum Home & Hospice Care: 100% coverage; in lieu of hospitalization; included doctor nurse, home health aide visits and home infusion therapy Dependent Coverage: spouse and unmarried children through the year in which they turn age 19 (or age 26 if a full-time student) received.Both parties hereby acknowledge that Appendix B contains any and all Memoranda of Agreement between the parties as of the date of ratification (March 20, 2012) of the collective bargaining agreement dated September 1, 2012 through August 31, 2015. Any purported Memoranda of Agreement dated prior to the above referenced ratification date that is not included in this Appendix is hereby agreed to be null and void and of no force or effect. This Appendix and the Memoranda of Agreement contained herein may be added to or deleted by mutual agreement of the parties, in writing, after the ratification date documented hereinabove and during the life of this Contract. The Memoranda of Agreement which shall be incorporated into this Contract as of March 20, 2012 and contained in Appendix B are referenced herein by date of execution and title/description as follows: Date Executed Title/Related to 1 March 1, 1983 Re: Computation of Seniority for Teachers on Layoff Pursuant to Article 22 2 May 8, 1989 Re: Change in Number of Daily Periods at WWHS (and related amendments) 3 December 11, 2002 Re: Article 42-1 Athletic Director - ▇▇▇▇ ▇▇▇▇▇▇▇ 4 March 11, 2008 Re: Establishment of Advisory Structure at Middle and High School Levels 5 March 10, 2009 Re: Pursuant to Article 15; Utilization of Paid Leave 6 March 24, 2009 Re: Pursuant to Article 9; Operation of Professional Development Academy 7 May 11, 2010 Re: Group 1 Participants to Race to the Top (Round 2) 8 May 11, 2010 Re: Changes to Opening and Closing Times of Schools 9 July 12, 2010 Re: 2011-12 Implementation of a RIDE Approved Teacher Evaluation System 10 July 12, 2011 Re: Collaborative Model for Inclusion Service Delivery 11 March 20, 2012 Re: Limited Waiver/Modification of Article 21 (Class Size Limits)

Preventive Care. Routine Well Adult Preventive Care Plan pays 100% 60After the plan deductible is met, your plan pays 70% after deductible Includes: office visitsIncludes coverage of additional services, pap smearsuch as urinalysis, mammogramEKG, gynecological exam, routine physical examination, x- rays, and other laboratory tests, prostate specific antigen test, colonoscopies, sigmoidoscopies and anoscopy, proctosigmoidoscopy, medical tests and other preventive services supplementing the standard Preventive Care benefit when billed as required by lawpart of office visit. Routine Well Child Care Immunizations Plan pays 100% 60After the plan deductible is met, your plan pays 70% after deductible Includes: office visitsMammogram, routine physical examinationPAP, laboratory tests, and PSA Tests Plan pays 100% Plan pays based on Place of Service. Coverage includes the associated Preventive Outpatient Professional Services.Diagnostic-related services are covered at the same level of benefits as other x-raysray and lab services, immunizationsbased on Place of Service. Inpatient Hospital Facility Services After the plan deductible is met, and other Preventive services as required by law. Flu Shots 100your plan pays 90% Paid Same As Network Eye Exam (including refractive exams) 100After the plan deductible is met, your plan pays 70% after Copayment Semi-Private Room: In-Network: Limited to 1 per Calendar Year, unless otherwise required by law Not Covered Organ Transplants 80% after deductible Not Covered Other Medical Services and Supplies 80% after deductible 60% after deductible Drugs and Products included on the Select Drugs and Products List Require presemi-certification and enrollment in the Select Drugs and Products Program Generic Drugs $10 copayment Formulary Brand Name Drugs $20 copayment Non-Formulary Brand Name Drugs $50 copayment Specialty Drugs May be available through the Select Drugs and Products Program Generic Drugs $20 copayment Formulary Brand Name Drugs $40 copayment Non-Formulary Brand Name Drugs $100 copayment NOTE: Charges for Prescription Drugs obtained through the Prescription Drug Benefit section will not apply to the Calendar Year Deductible. Prescription Drug expenses do apply to the private negotiated rate / Out-of-Pocket Maximum under Medical Benefits section of this Plan. Per Covered Person $2,800 $5,000 Per Family Unit $5,000 $10,000 Amounts applied Network: Limited to semi-private ratePrivate Room: In-Network: Limited to the Network Deductible and the Nonsemi-Network Deductible do not cross-apply. The Calendar Year deductible is waived for the following Covered Charges: - Network Preventive Care - Flu Shots Per Covered Person $2,800 $6,000 Per Family Unit $5,000 $12,000 The Plan will pay the designated percentage of Covered Charges until outprivate negotiated rate / Out-of-pocket amounts are reachedNetwork: Limited to semi-private rateSpecial Care Units (Intensive Care Unit (ICU), at which time Critical Care Unit (CCU)): In-Network: Limited to the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. The following charges do not apply toward the outnegotiated rate / Out-of-pocket Network: Limited to ICU/CCU daily room rate Inpatient Hospital Physician’s Visit/Consultation After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Inpatient Professional ServicesFor services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Facility Services After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Professional ServicesFor services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Short-Term Rehabilitation - PCP Short-Term Rehabilitation - Specialist After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Contract Year Maximums:Pulmonary Rehabilitation & Cognitive Therapy - Unlimited daysPhysical Therapy, Speech Therapy, Occupational Therapy and Chiropractic Care – 100 daysLimits are not applicable to mental health conditions for Physical, Speech and Occupational Therapies. Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Cardiac Rehabilitation - PCP Cardiac Rehabilitation - Specialist After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% After the plan deductible is met, yourplan pays 90% After the plan deductible is met,your plan pays 70% Contract Year Maximum:Cardiac Rehabilitation – 36 days Note: NonTherapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Home Health Care After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Unlimited days maximum per Contract Year Home Health Aide - 80 days per Contract Year Outpatient Private Duty Nursing$15,000 maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Skilled Nursing Facility, Rehabilitation Hospital, Sub-Precertification penalties Amounts over Usual Acute Facilities120 days maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Durable Medical EquipmentUnlimited maximum per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Breast Feeding Equipment and Reasonable Charge Amounts for products included on SuppliesLimited to the Select Drugs and Products List Room, Board, and Miscellaneous Expenses rental of one breast pump per birth as ordered or prescribed by a physician Includes related supplies Your plan pays 100% after After the plan deductible 80is met, your plan pays 70% after External Prosthetic Appliances (EPA) After the plan deductible Intensive is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Unlimited maximum per Contract Year Routine Foot Disorders Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Foot Orthotics After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Excludes surgical shoes or boots Once per Member per Contract Year Routine Eye Care Unit 100After the plan deductible is met, yourplan pays 90% after After the plan deductible 80is met,your plan pays 70% after One exam and refraction every Contract Year Eyeglasses for Accidental Injury After the plan deductible Surgical Facilities 100is met, your plan pays 90% after After the plan deductible 80is met, your plan pays 70% after One pair per lifetime Routine Hearing Exams After the plan deductible Other is met, your plan pays 90% After the plan deductible is met, your plan pays 70% One exam per Contract Year AcupunctureUnlimited days maximum per Contract Year Coverage for medical diagnosis only After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Hearing Aid After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Includes testing and fitting of hearing aid devices at Physician Office Visit cost share. WigsOne per Contract Year After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% InpatientThis benefit applies to the cost of the Infusion Therapy drugs administered in an Inpatient Facility. This benefit does not cover the related Facility or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Outpatient Facility ServicesThis benefit applies to the cost of the Infusion Therapy drugs administered in an Outpatient Facility. This benefit does not cover the related Facility or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Physician's OfficeThis benefit applies to the cost of targeted Infusion Therapy drugsadministered in the Physician’s Office. This benefit does not cover the related Office Visit or Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% HomeThis benefit applies to the cost of targeted Infusion Therapy drugs administered in the patient’s home. This benefit does not cover the related Professional charges. After the plan deductible is met, your plan pays 90% After the plan deductible is met, your plan pays 70% Note: Services 100% after where plan deductible 80% after deductible applies are noted with a caret (^). Benefit Physician's Office Independent Lab Emergency Room Visit 100% after deductible Paid Same As Network Room/ Urgent Care Facility 100Outpatient Facility In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Laboratory Covered same as plan's Physician’s Office Services Covered same as plan's Physician’s Office Services Plan pays 90%^ Plan pays 70%^ Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Plan pays 90% after ^ Plan pays 70% ^ Radiology Plan pays 90%^ Plan pays 70%^ Not Applicable Not Applicable Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Plan pays 90% ^ Plan pays 70% ^ Note: Services where plan deductible 80% after deductible Skilled Nursing applies are noted with a caret (^). Benefit Physician's Office Independent Lab Emergency Room/ Urgent Care Facility 100% after deductible 180 day Calendar Year maximum 80% after deductible 60 day Calendar Year maximum Inpatient visits 100% after deductible 80% after deductible Outpatient Facility In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network In-Network Out-of- Network Advanced Radiology Imaging Covered same as plan's Physician’s Office visits Services Covered same as plan's Physician’s Office Services Not Applicable Not Applicable Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Emergency Room/Urgent Care Services Covered same as plan's Outpatient Facility Services Covered same as plan's Outpatient Facility Services Advanced Radiology Imaging (including related services billed by the PhysicianARI) 100% after deductible 80% after deductible Surgery 100% after deductible 80% after deductible Anesthesia 100% after deductible Paid Same As Network Allergy services 100% after deductible 80% after deductible Diagnostic Testing (Xincludes MRI, MRA, CAT Scan, PET Scan, etc.Note: All lab and x-ray & Labservices, including ARI, provided at Inpatient Hospital are covered under Inpatient Hospital benefit Emergency Care Plan pays 90% ^ Plan pays 90% ^ Plan pays 90% ^ Urgent Care Plan pays 90% ^ Plan pays 90% ^ Not Applicable* *Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) 100generally are not covered. Hospice Plan pays 90% after deductible 80^ Plan pays 70% after deductible Independent Laboratory expenses 100^ Plan pays 90% after deductible Paid Same As Network Radiology/Pathology interpretation 100^ Plan pays 70% after deductible Paid Same As Network Home Health Care/Private Duty Nursing 100^ Bereavement Counseling Plan pays 90% after deductible 100 visit Calendar Year maximum 80^ Plan pays 70% after deductible 50 visit Calendar Year maximum NETWORK PROVIDERS NON-NETWORK PROVIDERS ^ Plan pays 90% ^ Plan pays 70% ^ Note: Services provided as part of Hospice Care 100% after deductible 180 day Lifetime maximum Not Covered Bereavement Counseling 2 visit Lifetime maximum Not Covered Ambulance Service 100% after deductible Paid Same As Network Jaw Joint/TMJ 100% after deductible Not Covered Wig After Chemotherapy 100% after deductible $400 Lifetime maximum 80% after deductible $400 Lifetime maximum Physical/Occupational Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Speech & Vision Therapy 100% after deductible Limited to 20 visits for each therapy per Calendar Year 80% after deductible Limited to 10 visits for each therapy per Calendar Year Spinal Manipulation/ Chiropractic 100% after deductible 15 visit Calendar Year maximum 80% after deductible 15 visit Calendar Year maximum Mental Disorders/Substance Abuse Paid based on the type of service(s) received.Program