Common use of Preventive Care Clause in Contracts

Preventive Care. Pediatric No Copay No Copay Adult No Copay No Copay Vision No Copay No Copay Covered once every 24 months Covered once every 24 months Hearing No Copay No Copay Screening part of physical exam Screening part of physical exam Gynecological No Copay No Copay Medical Services Medical Office Visit Copay Copay Outpatient PT/OT/ST/Chiro. Copay Copay 60 Combined Days 60 Combined Days per calendar year per member per calendar year per member Allergy Services office visits and testing; Copay office visits and testing; Copay No copay for injections No copay for injections Diagnostic Lab & X-ray Covered Covered Inpatient Medical Services Covered Covered Surgery Fees Covered Covered Office Surgery Covered Covered Outpatient MH/SA Copay based on date of service Copay based on date of service Emergency Care Emergency Room $75 Copay (waived if admitted) $75 Copay (waived if admitted) Sudden & Serious Guidelines Sudden & Serious Guidelines Urgent Care $25 Copay $25 Copay Ambulance Covered Covered APPENDIX C Town of Manchester, Connecticut BENEFIT OAP Plus OAP Basic Inpatient Hospital General/Medical/Surgical/ Pre-cert only for Out-of-Network Maternity (Semi-private) $200 Copay Effective 7/1/2017 $200 Copay Effective 7/1/2017 Ancillary Services Covered Covered Medication, Supplies Psychiatric Unlimited days Unlimited days Substance Abuse/Detox Unlimited days Unlimited days Skilled Nursing/Rehabilitation Covered up to 180 days per calendar year Covered up to 180 days per calendar year Facility Hospice Covered Covered Outpatient Hospital Outpatient Surgery Facility Charges $100 Copay $100 Copay (Prior Authorization Required) (Prior Authorization Required) Diagnostic Lab & X-ray Covered Covered Pre-Admission Testing Covered Covered Other Services Durable Medical Equipment Covered Covered Prosthetics Covered Covered Home Health Care Unlimited days Unlimited days (Prior Authorization Required) (Prior Authorization Required) Pharmacy Benefits Prescriptions $5/$20/$35 $5/$20/$35 Unlimited maximum Unlimited maximum Three Tier Formulary RX Rider Three Tier Formulary RX Rider All Benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum for the OAP Plus and OAP Basic plans. ELIGIBILITY: Dependent children covered to age 26 for medical and prescription plans. APPENDIX C Town of Manchester, Connecticut BENEFIT High Deductible Health Plan/ BENEFIT High Deductible Health Plan/ Costshares Health Savings Account Inpatient Hospital Health Savings Account Deductible - $2,000/$4,000 General/Medical/Surgical/ Covered 100% after plan deductible met Coinsurance - 100% after plan deductible met Maternity (Semi-private) for in network services $4,000/$8,000 out of pocket maximum Ancillary Services Covered 100% after plan deductible met Coinsurance - 80% after plan deductible met Medication, Supplies for out of network services Psychiatric Covered 100% after plan deductible met Employer Contribution Unlimited days $1,000 single coverage $2,000 double or family coverage Substance Abuse/Detox Covered 100% after plan deductible met Unlimited days Lifetime Maximum In-Network - Unlimited Skilled Nursing/Rehabilitation Covered 100% after plan deductible met Lifetime Maximum Out-Of-Network - Unlimited Facility Covered up to 180 days per calendar year Preventive Care Hospice Covered 100% after plan deductible met Pediatric Covered Outpatient Hospital Adult Covered Outpatient Surgery Covered 100% after plan deductible met Facility Charges (Prior Authorization Required) Hearing Covered Diagnostic Lab & X-ray Covered 100% after plan deductible met Screening part of physical exam Gynecological Covered Pre-Admission Testing Covered 100% after plan deductible met Medical Services Other Services Medical Office Visit Covered 100% after plan deductible met Durable Medical Equipment Covered 100% after plan deductible met Outpatient PT/OT/ST/Chiro. Covered 100% after plan deductible met Prosthetics Covered 100% after plan deductible met 60 Combined Days per calendar year per member Home Health Care Covered 100% after plan deductible met Allergy Services Covered 100% after plan deductible met Unlimited days (Prior Authorization Required) Vision Covered 100% after plan deductible met Diagnostic Lab & X-ray Covered 100% after plan deductible met Covered once every 24 months Prescriptions Rx copays apply after the deductible is met $5/$20/$35 Three Tier Formulary RX Rider Surgery Fees Covered 100% after plan deductible met All benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum. Emergency Care ELIGIBILITY: Dependent children covered to age 26 for medical and Emergency Room Covered 100% after plan deductible met prescription plans. Urgent Care Covered 100% after plan deductible met Ambulance Covered 100% after plan deductible met Matrix CIGNA HDHP-HSA Res Sup 07/01/2020

Preventive Care. Pediatric Well Care, including immunizations 100% No Copay Subject to deductible, coinsurance and R&C Adult Routine Physical Examinations 100% No Copay Adult Subject to deductible, coinsurance and R&C Gynecological Routine Examinations l 00% No Copay Subject to deductible, coinsurance and R&C Mammography Services 100% No Copay Vision No Copay No Copay Covered once every 24 months Covered once every 24 months Subject to deductible, coinsurance and R&C Hearing No Copay No Copay Screening part of physical exam Screening part of physical exam Gynecological No Copay No Copay Examinations $20 co-payment Subject to deductible, coinsurance and R&C Medical Services Medical Office Visit Copay Copay $20 co-payment Subject to deductible, coinsurance and R&C Outpatient PT/OT/ST/Chiro. Copay Copay 60 - Occupational, Physical and Speech Therapy, Pulmonary Rehabilitation, Cognitive Therapy, Cardiac Rehabilitation $20 co-payment Subject to deductible, coinsurance and R&C Combined Days 60 Combined Days 30 visit maximum per calendar year; 36 visit maximum per calendar year per member for Cardiac Rehabilitation BENEFITS IN-NETWORK OUT-OF-NETWORK Chiropractic Therapy $20 Co-payment Subject to deductible, coinsurance and R&C 30 visit maximum per calendar year per member Allergy Services office visits $20 co-payments Allergy shots including bee venom extract Office visit and testing; Copay office visits allergy shots combined subject to one co- payment Subject to deductible, coinsurance and testing; Copay No copay for injections No copay for injections R&C Diagnostic Lab & X-ray Covered Covered Ray Services 100% of covered services Subject to deductible, coinsurance and R&C Inpatient - Medical Services Covered Covered 100% of covered expenses $100 co-payment per admission Subject to deductible, coinsurance and R&C Prior Authorization required for certain procedures Surgery Fees Covered Covered l 00% of covered expenses Subject to deductible, coinsurance and R&C Prior Authorization required for certain procedures Office Surgery Covered Covered $20 co-payment Subject to deductible, coinsurance and R&C I Prior Authorization required for certain procedures Mental Health and Substance Abuse Prior authorization required for certain procedures Inpatient Hospital Psychiatric Biologically Based[i I 00% of covered expenses $100 per admission Subject to deductible, coinsurance, and R&C Outpatient MH/SA Copay based Mental Health Biologically Based $20 co-payment Subject to deductible, coinsurance, and R&C Inpatient Hospital Psychiatric Non- Biologically Based l 00% of covered expenses $100 per admission Subject to deductible, coinsurance and R&C As per MHPA no limits on date MH benefits. Outpatient Mental Health Non-Biologically Based $20 co-payment Subject to deductible, coinsurance and R&C. As per MHPA no limits on MH benefits. Inpatient Hospital Substance Abuse and / or Alcoholism 100% of service Copay based covered expenses $100 per admission Subject to deductible, coinsurance and R&C Outpatient Substance Abuse and/ or Alcoholism $20 co-.payment Subject to deductible, coinsurance, and R&C As per MHPA no limits on date of service MH benefits. Emergency Care Emergency Room $75 Copay (waived 150 co-payment Waived if admitted) admitted $150 co-payment Waived if admitted Urgent Care Center $75 Copay co-payment $75 co-payment Walk-In Center[ $75 co-payment $75 co-payment Ambulance 100% of covered expenses I 00% of covered expenses Ambulance services used as non-emergency transportation (waived if admittede.g. transportation from hospital back home) Sudden & Serious Guidelines Sudden & Serious Guidelines Urgent Care $25 Copay $25 Copay Ambulance Covered Covered APPENDIX C Town of Manchester, Connecticut BENEFIT OAP Plus OAP Basic generally are not covered Inpatient Hospital General/Medical/Surgical/ Pre-cert only for Out-of-Network Maternity (Semisemi-private) private)/ Intensive Care l00% of covered expenses $200 Copay Effective 7/1/2017 $200 Copay Effective 7/1/2017 100 per admission Subject to deductible, coinsurance and R&C Subject to non-emergency pre-certification Ancillary Services Covered Covered Medication(medication, Supplies Psychiatric Unlimited days Unlimited days Substance Abuse/Detox Unlimited days Unlimited days Skilled Nursing/Rehabilitation Covered up supplies) l00% of covered expenses Subject to 180 days per calendar year Covered up to 180 days per calendar year Facility Hospice Covered Covered deductible, coinsurance and R&C I BENEFITS I IN-NETWORK OUT-OF-NETWORK Outpatient Hospital Outpatient Surgery - Surgery, Facility Charges $100 Copay $100 Copay (Prior Authorization Required) (Prior Authorization Required) 100% of covered services Subject to deductible, coinsurance and R&C Diagnostic Lab & X-ray Covered Covered Ray 100% of covered services Subject to deductible, coinsurance and R&C Pre-Admission Testing Covered Covered 100% of covered services Subject to deductible, coinsurance and R&C Other Services Outpatient Short-Term Rehabilitative Therapy 100% of covered expenses Subject to deductible, coinsurance and R&C 30 days for all therapies combined (Physical Therapy, Speech Therapy Occupational Therapy, Pulmonary Rehab, Cognitive Therapy) Skilled Nursing Facility l 00% of covered expenses Subject to deductible, coinsurance and R&C 60 day maximum per calendar year Hospice 100% of covered expenses 100% of covered expenses Individuals with life expectancy of 6 months or less Durable Medical Equipment Covered Covered Prosthetics Covered Covered Home Health Care Unlimited days Unlimited days (Prior Authorization Required) (Prior Authorization Required) Pharmacy Benefits Prescriptions $5/$20/$35 $5/$20/$35 Unlimited maximum Unlimited maximum Three Tier Formulary RX Rider Three Tier Formulary RX Rider All Benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum for the OAP Plus and OAP Basic plans. ELIGIBILITY: Dependent children covered to age 26 for medical and prescription plans. APPENDIX C Town of Manchester, Connecticut BENEFIT High Deductible Health Plan/ BENEFIT High Deductible Health Plan/ Costshares Health Savings Account Inpatient Hospital Health Savings Account Deductible - $2,000/$4,000 General/Medical/Surgical/ Covered 100% after plan deductible met Coinsurance - 100% after plan deductible met Maternity (Semi-private) for in network services $4,000/$8,000 out of pocket maximum Ancillary Services Covered 100% after plan deductible met Coinsurance - 80% after plan deductible met Medication, Supplies for out of network services Psychiatric Covered 100coinsurance 50% after plan deductible met Employer Contribution Unlimited days coinsurance $1,000 single coverage $2,000 double or family coverage Substance Abuse/Detox Covered 100% after plan deductible met Unlimited days Lifetime Maximum In-Network - Unlimited Skilled Nursing/Rehabilitation Covered 100% after plan deductible met Lifetime Maximum Out-Of-Network - Unlimited Facility Covered up to 180 days 10,000 maximum per calendar year Preventive Care Hospice Covered 100External Prosthetic Appliances l 00% after plan deductible met Pediatric Covered Outpatient Hospital Adult Covered Outpatient Surgery Covered 100% after plan deductible met Facility Charges (Prior Authorization Required) Hearing Covered Diagnostic Lab & X-ray Covered 100% after plan deductible met Screening part of physical exam Gynecological Covered Pre-Admission Testing Covered 100% after plan deductible met Medical Services Other Services Medical Office Visit Covered 100% after plan deductible met Durable Medical Equipment Covered 100% after plan deductible met Outpatient PT/OT/ST/Chiro. Covered 100% after plan deductible met Prosthetics Covered 100% after plan deductible met 60 Combined Days per calendar covered expenses Subject to deductible, coinsurance and R&C $5,000 maximum for prosthetic@ Calendar year per member replacement parts maximum $500 Home Health Care Covered 100% after of covered expenses with prior approval Subject to deductible, coinsurance and R&C Prescription Drugs $5 Generic $25 Brand Name $40 Non Formulary Brand Name Mail Order 90 Day Supply $l0 Generic $50 Preferred Brand $80 Non-Preferred Brand Name Emergency pharmacy services only Dependent/Student Eligibility To age 26 as per PPACA DENTAL AND OPTICAL The City will provide a PPO dental plan deductible met Allergy Services Covered as follows: City of Stamford – SPA Group #4529 - 0003 Delta Dental PPOSM plus Premier Effective November 1, 2016 Calendar Year Deductible • Per Person $50 • Family Aggregate Maximum $100 Plan Pays: Preventive & Diagnostic (No Deductible) 100% after plan deductible met Unlimited days (Prior Authorization Required) Vision Covered 100% after plan deductible met Diagnostic Lab & • Exams, Cleanings, Bitewing X-ray Covered 100Rays (2 per calendar year per person) • Fluoride Treatment (For children to age 19) Remaining Basic (After Deductible) 80% after plan deductible met Covered once every 24 months Prescriptions Rx copays apply after the deductible is met • Fillings, Extractions, Root Canals (Endodontics) • Periodontal, Oral Surgery • Repair of Dentures • Sealants (To age 14) Crowns & Prosthodontics (After Deductible) 75% • Crowns, Gold Restorations • Bridgework, Full & Partial Dentures • Implants Calendar Year Maximum (Per Person) $5/$20/$35 Three Tier Formulary RX Rider Surgery Fees Covered 1002,000 Orthodontia (Dependent Children Only) • Coinsurance 50% after plan deductible met All benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a • Lifetime Maximum $5,000 lifetime maximum. Emergency Care ELIGIBILITY: 2,500 Dependent children are covered to age 26 26. Delta Dental has two networks available under this plan. The Delta Dental Premier® network is the largest of the Delta Dental networks with over 368,000 participating dentist offices nationally (80%+). Delta Dental PPO5M is a smaller, but more discounted network with over 293,000 participating dentist offices nationwide. Delta Dental PPO5M fees are on average 20% less than Delta Dental Premier®. You may use any fully licensed dentist under this plan, but it is to your advantage to use a network dentist, especially PPO, since they accept the Delta Dental allowance as their maximum charge and cannot xxxx Delta Dental patients for medical amounts above this level. Participating dentists will be paid directly by Delta Dental for covered services. Non-participating dentists will xxxx you directly, and Emergency Room Covered 100% after Delta Dental will make claim payment directly to you. You will maximize benefits and reduce paperwork by using a Delta Dental participating dentist. If you do not have a dentist, you may obtain a current listing of participating dentists in any area, by calling 0-000 XXXXX XX (0-000-000-0000). Provide your zip code to the representative and a directory for that area will be mailed to your home. If you have Internet access, you may also visit our website at xxxxxxxxxxxxx.xxx to locateparticipating dentists. At the time of your first appointment, tell the dentist that you are covered under this program and provide your group number and ID number. Your dependents, if covered, should provide the employee's ID number. Claim questions and other information needs should be directed to Delta Dental's customer service department at 1-800-452-9310. This overview contains a general description of your dental care program for your use as a convenient reference. Complete details of your program appear in the group contract between your plan deductible met prescription planssponsor and Delta Dental of New Jersey, Inc. which governs the benefits and operation of your program. Urgent Care Covered 100% after plan deductible met Ambulance Covered 100% after plan deductible met Matrix CIGNA HDHPIn CT, Delta Dental Insurance Company writes dental coverage on an insured basis and Delta Dental of New Jersey administers self-HSA Res Sup 07/01/2020funded dental benefit programs. The group contract would control if there should be any inconsistency or difference between its provisions and the information in this overview.

Preventive Care. Pediatric No Copay No Copay Adult No Copay No Copay Vision No Copay No Copay Covered once every 24 months Covered once every 24 months Hearing No Copay No Copay Screening part of Routine Well Care 100% 50% after deductible Includes: office visits, pap smear, mammogram, gynecological exam, routine physical exam Screening part of examination, x-rays, laboratory tests, prostate specific antigen test, colonoscopies, sigmoidoscopies and anoscopy, proctosigmoidoscopy, medical tests and other preventive services as required by law. NETWORK PROVIDERS NON-NETWORK PROVIDERS Routine Well Child Care 100% 50% after deductible Includes: office visits, routine physical exam Gynecological No Copay No Copay examination, laboratory tests, x-rays, immunizations, and other Preventive services as required by law. Other Medical Services Medical Office Visit Copay Copay Outpatient PT/OT/ST/Chiroand Supplies 50% after deductible 50% 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 PRESCRIPTION DRUG BENEFIT SCHEDULE MINIMUM VALUE PLAN PRESCRIPTION DRUG BENEFIT BENEFIT Pharmacy Option (30 Day Supply) Generic Drugs 50% Preferred Brand Name Drugs 50% Non-Preferred Brand Name Drugs 50% Specialty Drugs May be available through the Select Drugs and Products Program Mail Order Option (90 Day Supply) Generic Drugs 50% Preferred Brand Name Drugs 50% Non-Preferred Brand Name Drugs 50% Specialty Drugs May be available through the Select Drugs and Products Program Refer to the Prescription Drug Section for details on the Prescription Drug benefit. Copay Copay 60 Combined Days 60 Combined Days per calendar year per member per calendar year per member Allergy Services office visits Products include on the Plan Select Drugs and testing; Copay office visits Products List require prior authorization and testing; Copay No copay for injections No copay for injections Diagnostic Lab & X-ray Covered Covered Inpatient Medical Services Covered Covered Surgery Fees Covered Covered Office Surgery Covered Covered Outpatient MH/SA Copay based on date of service Copay based on date of service Emergency Care Emergency Room $75 Copay (waived if admitted) $75 Copay (waived if admitted) Sudden & Serious Guidelines Sudden & Serious Guidelines Urgent Care $25 Copay $25 Copay Ambulance Covered Covered APPENDIX C Town of Manchester, Connecticut BENEFIT OAP Plus OAP Basic Inpatient Hospital General/Medical/Surgical/ Pre-cert only for enrollment in the Select Drugs and Products Program. Note: Prescription Drug expenses under the Prescription Drug Program do not apply to the Calendar Year Deductible. Prescription Drug expenses do apply to the Out-of-Network Maternity (Semi-private) $200 Copay Effective 7/1/2017 $200 Copay Effective 7/1/2017 Ancillary Services Covered Covered MedicationPocket Maximum under Medical Benefits section of this Plan. EXHIBIT G-1 GRIEVANCE PROCEDURE FORM Aggrieved Person, Supplies Psychiatric Unlimited days Unlimited days Substance Abuse/Detox Unlimited days Unlimited days Skilled Nursing/Rehabilitation Covered up Persons, and/or Association Address Phone School Principal Date Grievance Occurred Date of Formal Filing Person or Persons to 180 days per calendar year Covered up to 180 days per calendar year Facility Hospice Covered Covered Outpatient Hospital Outpatient Surgery Facility Charges $100 Copay $100 Copay (Prior Authorization Required) (Prior Authorization Required) Diagnostic Lab & X-ray Covered Covered Pre-Admission Testing Covered Covered Other Services Durable Medical Equipment Covered Covered Prosthetics Covered Covered Home Health Care Unlimited days Unlimited days (Prior Authorization Required) (Prior Authorization Required) Pharmacy Benefits Prescriptions $5/$20/$35 $5/$20/$35 Unlimited maximum Unlimited maximum Three Tier Formulary RX Rider Three Tier Formulary RX Rider All Benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITYWhom Grievance is Directed Initiated on Level Statement of Grievance: Coverage is subject to a $5,000 lifetime maximum for the OAP Plus and OAP Basic plans. ELIGIBILITY: Dependent children covered to age 26 for medical and prescription plans. APPENDIX C Town of Manchester, Connecticut BENEFIT High Deductible Health Plan/ BENEFIT High Deductible Health Plan/ Costshares Health Savings Account Inpatient Hospital Health Savings Account Deductible - $2,000/$4,000 General/Medical/Surgical/ Covered 100% after plan deductible met Coinsurance - 100% after plan deductible met Maternity (Semi-private) for in network services $4,000/$8,000 out of pocket maximum Ancillary Services Covered 100% after plan deductible met Coinsurance - 80% after plan deductible met Medication, Supplies for out of network services Psychiatric Covered 100% after plan deductible met Employer Contribution Unlimited days $1,000 single coverage $2,000 double or family coverage Substance Abuse/Detox Covered 100% after plan deductible met Unlimited days Lifetime Maximum In-Network - Unlimited Skilled Nursing/Rehabilitation Covered 100% after plan deductible met Lifetime Maximum Out-Of-Network - Unlimited Facility Covered up to 180 days per calendar year Preventive Care Hospice Covered 100% after plan deductible met Pediatric Covered Outpatient Hospital Adult Covered Outpatient Surgery Covered 100% after plan deductible met Facility Charges (Prior Authorization Required) Hearing Covered Diagnostic Lab & X-ray Covered 100% after plan deductible met Screening What part of physical exam Gynecological Covered Pre-Admission Testing Covered 100% after plan deductible met Medical Services Other Services Medical Office Visit Covered 100% after plan deductible met Durable Medical Equipment Covered 100% after plan deductible met Outpatient PT/OT/ST/Chirothe definition of the grievance is violated? Set forth the language and source violated. Covered 100% after plan deductible met Prosthetics Covered 100% after plan deductible met 60 Combined Days per calendar year per member Home Health Care Covered 100% after plan deductible met Allergy Services Covered 100% after plan deductible met Unlimited days Action Requested: Have you discussed this with your immediate supervisor? Yes No. Grievant EXHIBIT G-2 GRIEVANCE DECISIONS LEVEL ONE (Prior Authorization RequiredFormal) Vision Covered 100% after plan deductible met Diagnostic Lab & X-ray Covered 100% after plan deductible met Covered once every 24 months Prescriptions Rx copays apply after the deductible is met $5/$20/$35 Three Tier Formulary RX Rider Surgery Fees Covered 100% after plan deductible met All benefits listed are for In-Network. For Out-of-Network benefitsDECISION Date Signature Administrative Representative Signature Aggrieved and/or WEA Representative* LEVEL TWO (Formal) DECISION Date Signature Administrative Representative Signature Aggrieved and/or WEA Representative* LEVEL THREE (Formal) DECISION Date Signature Administrative Representative Signature Aggrieved and/or WEA Representative* WHERE DECISION REQUIRES ADDITIONAL SPACE, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum. Emergency Care ELIGIBILITY: Dependent children covered to age 26 for medical and Emergency Room Covered 100% after plan deductible met prescription plans. Urgent Care Covered 100% after plan deductible met Ambulance Covered 100% after plan deductible met Matrix CIGNA HDHP-HSA Res Sup 07/01/2020ATTACH PAGES AS NECESSARY.

Preventive Care. Pediatric No Copay No Copay Adult No Copay No Copay Vision No Copay No Copay Covered once every 24 months Covered once every 24 months Hearing No Copay No Copay Screening part of physical exam Screening part of physical exam Gynecological No Copay No Copay Medical Services Medical Office Visit Copay Copay Outpatient PT/OT/ST/Chiro. Copay Copay 60 Combined Days 60 Combined Days per calendar year per member per calendar year per member Allergy Services office visits and testing; Copay office visits and testing; Copay No copay for injections No copay for injections Diagnostic Lab & XMammograms Pap Tests Well Baby Care - $10 Co-ray Covered Covered Inpatient Medical Services Covered Covered Surgery Fees Covered Covered Office Surgery Covered Covered Outpatient MH/SA Copay based on date of service Copay based on date of service Emergency Care Emergency Room $75 Copay (waived if admitted) $75 Copay (waived if admitted) Sudden & Serious Guidelines Sudden & Serious Guidelines Urgent Care $25 Copay $25 Copay Ambulance Covered Covered APPENDIX C Town of Manchesterpayment Per Visit, Connecticut BENEFIT OAP Plus OAP Basic Inpatient Hospital General/Medical/Surgical/ Pre-cert only for Out-of-Network Maternity (Semi-private) $200 Copay Effective 7/1/2017 $200 Copay Effective 7/1/2017 Ancillary Services Covered Covered Medication, Supplies Psychiatric Unlimited days Unlimited days Substance Abuse/Detox Unlimited days Unlimited days Skilled Nursing/Rehabilitation Covered up then 100% Coverage Up to 180 days per calendar year Covered up to 180 days per calendar year Facility Hospice Covered Covered Outpatient Hospital Outpatient Surgery Facility Charges Our Allowance DEDUCTIBLE SERVICES $100 Copay $100 Copay Deductible Per Person (Prior Authorization RequiredMaximum of 2 Per Family) (Prior Authorization Required) Diagnostic Lab & X-ray Covered Covered Pre-Admission Testing Covered Covered Other Services Durable Medical Equipment Covered Covered Prosthetics Covered Covered Home Health $1,000,000 Lifetime Maximum Office Visit Coverage PRESCRIPTIONS Preferred Rx – 80% Coverage for Network Providers MISCELLANEOUS BENEFITS Student Coverage to Age 25 No Lifetime Maximum Organ Transplant Rider Radiation Therapy Services Paid In Full 80% Coverage for Infertility Treatment Mental Health/Substance Abuse Visits Managed Benefits Program Vision Care Unlimited days Unlimited days (Prior Authorization RequiredPPO/Comprehensive) (Prior Authorization Required) Pharmacy Benefits Prescriptions $5/$20/$35 $5/$20/$35 Unlimited maximum Unlimited maximum Three Tier Formulary RX Rider Three Tier Formulary RX Rider All Benefits listed are NON CLASSIFIED GROUPING Surgical-Medical Coverage for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum for the OAP Plus and OAP Basic plans. ELIGIBILITY: Dependent children covered to age 26 for medical and prescription plans. APPENDIX C Town of Manchester, Connecticut BENEFIT High Deductible Health Plan/ BENEFIT High Deductible Health Plan/ Costshares Health Savings Account Inpatient Hospital Health Savings Account Deductible Chemotherapy Drugs Only Vision - $2,000/$4,000 General50 Maximum for Frames and Lenses Per Calendar Year $10 Copay for Vision Exams APPENDIX D LINCOLN STANDARD PLAN COVERAGE GUIDELINES 50% Cov for OP MHSA for RI or Othr Plans Non-Ntwk PPO Prov; 80% Cov all Sve Othr RI or Othr Plans Non-Ntwk PPO Prov up to an OOP Mx $3000I/3 Per Fam Per Calry Aggr BT Hosp & Surg-Med LOB Excel Pedi/MedicalIVF/Surgical/ Covered 100MH/SA; 80% after plan deductible met Coinsurance - 100% after plan deductible met Maternity (Cov Infertility Treatment HOSPITAL COVERAGE Unlimited Days of Care Semi-privatePrivate Room 45 Inpatient Mental Health Days Emergency Room Care $100 Emergency Room Copayment Good Health Benefit (w/Credit) for in network services $4,000/$8,000 out of pocket maximum Ancillary Services Covered 100% after plan deductible met Coinsurance - 80% after plan deductible met Medication, Supplies for out of network services Psychiatric Covered 100% after plan deductible met Employer Contribution Unlimited days $1,000 single coverage $2,000 double or family coverage Substance AbuseSURGICAL/Detox Covered 100% after plan deductible met Unlimited days Lifetime Maximum In-Network - Unlimited Skilled Nursing/Rehabilitation Covered 100% after plan deductible met Lifetime Maximum Out-Of-Network - Unlimited Facility Covered up to 180 days per calendar year Preventive Care Hospice Covered 100% after plan deductible met Pediatric Covered Outpatient Hospital Adult Covered Outpatient Surgery Covered 100% after plan deductible met Facility Charges (Prior Authorization Required) Hearing Covered Diagnostic Lab & X-ray Covered 100% after plan deductible met Screening part of physical exam Gynecological Covered Pre-Admission Testing Covered 100% after plan deductible met Medical Services Other Services Medical Office Visit Covered 100% after plan deductible met MEDICAL COVERAGE 12 Chiropractic Visits Per Calendar Year Durable Medical Equipment Covered 100% after plan deductible met Outpatient PT/OT/ST/Chiro. Covered 100% after plan deductible met Prosthetics Covered 100% after plan deductible met 60 Combined Days per calendar year per member Home Health Care Covered 100% after plan deductible met Allergy Services Covered 100% after plan deductible met Unlimited days (Prior Authorization Required) Vision Covered 100% after plan deductible met Diagnostic Tests, Lab & and X-ray Covered 100Ray Coverage Including Mammograms and Pap Tests Office Visit Coverage Inpatient/Outpatient Surgery, Anesthesia Coverage Maternity Care $15 Office Visit Copayment Per Individual Session for Outpatient Mental Health/$10 Office Visit Copayment Per Group Session for Outpatient Mental Health 80% after plan deductible met Covered once every 24 months Prescriptions Rx copays apply after the deductible is met Coverage for Clinic, Home Infusion, Home Care, Prosthesis, Durable Medical Equipment, Private Duty Nursing, Cardiac Rehabilitation, Ambulance, Professional Therapy, Injections, Oxygen, Supplies and Drugs, $5/$20/$35 Three Tier Formulary RX Rider Surgery Fees Covered 100% after plan deductible met All benefits listed 10 Office Visit Copayment (including chiropractic visits) $15 Office Visit Copayment for Allergy and Dermatology Injectable Prescription Drugs Excluding Oral Contraceptives are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum. Emergency Care ELIGIBILITY: Dependent children covered to age 26 for medical and Emergency Room Covered 100% after plan deductible met prescription plans. Urgent Care Covered 100% after plan deductible met Ambulance Covered 100% after plan deductible met Matrix CIGNA HDHP-HSA Res Sup 07/01/2020Covered

Preventive Care. Pediatric Well Care, including immunizations 100% No Copay Subject to deductible, coinsurance and R&C Adult Routine Physical Examinations 100% No Copay Adult Subject to deductible, coinsurance and R&C Gynecological Routine Examinations l 00% No Copay Subject to deductible, coinsurance and R&C Mammography Services 100% No Copay Vision No Copay No Copay Covered once every 24 months Covered once every 24 months Subject to deductible, coinsurance and R&C Hearing No Copay No Copay Screening part of physical exam Screening part of physical exam Gynecological No Copay No Copay Examinations $20 co-payment Subject to deductible, coinsurance and R&C Medical Services Medical Office Visit Copay Copay $20 co-payment Subject to deductible, coinsurance and R&C Outpatient PT/OT/ST/Chiro. Copay Copay 60 - Occupational, Physical and Speech Therapy, Pulmonary Rehabilitation, Cognitive Therapy, Cardiac Rehabilitation $20 co-payment Subject to deductible, coinsurance and R&C Combined Days 60 Combined Days 30 visit maximum per calendar year; 36 visit maximum per calendar year per member for Cardiac Rehabilitation BENEFITS IN-NETWORK OUT-OF-NETWORK Chiropractic Therapy $20 Co-payment Subject to deductible, coinsurance and R&C 30 visit maximum per calendar year per member Allergy Services office visits $20 co-payments Allergy shots including bee venom extract Office visit and testing; Copay office visits allergy shots combined subject to one co- payment Subject to deductible, coinsurance and testing; Copay No copay for injections No copay for injections R&C Diagnostic Lab & X-ray Covered Covered Ray Services 100% of covered services Subject to deductible, coinsurance and R&C Inpatient - Medical Services Covered Covered 100% of covered expenses $100 co-payment per admission Subject to deductible, coinsurance and R&C Prior Authorization required for certain procedures Surgery Fees Covered Covered l 00% of covered expenses Subject to deductible, coinsurance and R&C Prior Authorization required for certain procedures Office Surgery Covered Covered $20 co-payment Subject to deductible, coinsurance and R&C I Prior Authorization required for certain procedures Mental Health and Substance Abuse Prior authorization required for certain procedures Inpatient Hospital Psychiatric Biologically Based[i I 00% of covered expenses $100 per admission Subject to deductible, coinsurance, and R&C Outpatient MH/SA Copay based Mental Health Biologically Based $20 co-payment Subject to deductible, coinsurance, and R&C Inpatient Hospital Psychiatric Non- Biologically Based l 00% of covered expenses $100 per admission Subject to deductible, coinsurance and R&C As per MHPA no limits on date MH benefits. Outpatient Mental Health Non-Biologically Based $20 co-payment Subject to deductible, coinsurance and R&C. As per MHPA no limits on MH benefits. Inpatient Hospital Substance Abuse and / or Alcoholism 100% of service Copay based covered expenses $100 per admission Subject to deductible, coinsurance and R&C Outpatient Substance Abuse and/ or Alcoholism $20 co-.payment Subject to deductible, coinsurance, and R&C As per MHPA no limits on date of service MH benefits. Emergency Care Emergency Room $75 Copay (waived 150 co-payment Waived if admitted) admitted $150 co-payment Waived if admitted Urgent Care Center $75 Copay co-payment $75 co-payment Walk-In Center[ $75 co-payment $75 co-payment Ambulance 100% of covered expenses I 00% of covered expenses Ambulance services used as non-emergency transportation (waived if admittede.g. transportation from hospital back home) Sudden & Serious Guidelines Sudden & Serious Guidelines Urgent Care $25 Copay $25 Copay Ambulance Covered Covered APPENDIX C Town of Manchester, Connecticut BENEFIT OAP Plus OAP Basic generally are not covered Inpatient Hospital General/Medical/Surgical/ Pre-cert only for Out-of-Network Maternity (Semisemi-private) private)/ Intensive Care l00% of covered expenses $200 Copay Effective 7/1/2017 $200 Copay Effective 7/1/2017 100 per admission Subject to deductible, coinsurance and R&C Subject to non-emergency pre-certification Ancillary Services Covered Covered Medication(medication, Supplies Psychiatric Unlimited days Unlimited days Substance Abuse/Detox Unlimited days Unlimited days Skilled Nursing/Rehabilitation Covered up supplies) l00% of covered expenses Subject to 180 days per calendar year Covered up to 180 days per calendar year Facility Hospice Covered Covered deductible, coinsurance and R&C I BENEFITS I IN-NETWORK OUT-OF-NETWORK Outpatient Hospital Outpatient Surgery - Surgery, Facility Charges $100 Copay $100 Copay (Prior Authorization Required) (Prior Authorization Required) 100% of covered services Subject to deductible, coinsurance and R&C Diagnostic Lab & X-ray Covered Covered Ray 100% of covered services Subject to deductible, coinsurance and R&C Pre-Admission Testing Covered Covered 100% of covered services Subject to deductible, coinsurance and R&C Other Services Outpatient Short-Term Rehabilitative Therapy 100% of covered expenses Subject to deductible, coinsurance and R&C 30 days for all therapies combined (Physical Therapy, Speech Therapy Occupational Therapy, Pulmonary Rehab, Cognitive Therapy) Skilled Nursing Facility l 00% of covered expenses Subject to deductible, coinsurance and R&C 60 day maximum per calendar year Hospice 100% of covered expenses 100% of covered expenses Individuals with life expectancy of 6 months or less Durable Medical Equipment Covered Covered Prosthetics Covered Covered Home Health Care Unlimited days Unlimited days (Prior Authorization Required) (Prior Authorization Required) Pharmacy Benefits Prescriptions $5/$20/$35 $5/$20/$35 Unlimited maximum Unlimited maximum Three Tier Formulary RX Rider Three Tier Formulary RX Rider All Benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum for the OAP Plus and OAP Basic plans. ELIGIBILITY: Dependent children covered to age 26 for medical and prescription plans. APPENDIX C Town of Manchester, Connecticut BENEFIT High Deductible Health Plan/ BENEFIT High Deductible Health Plan/ Costshares Health Savings Account Inpatient Hospital Health Savings Account Deductible - $2,000/$4,000 General/Medical/Surgical/ Covered 100% after plan deductible met Coinsurance - 100% after plan deductible met Maternity (Semi-private) for in network services $4,000/$8,000 out of pocket maximum Ancillary Services Covered 100% after plan deductible met Coinsurance - 80% after plan deductible met Medication, Supplies for out of network services Psychiatric Covered 100coinsurance 50% after plan deductible met Employer Contribution Unlimited days coinsurance $1,000 single coverage $2,000 double or family coverage Substance Abuse/Detox Covered 100% after plan deductible met Unlimited days Lifetime Maximum In-Network - Unlimited Skilled Nursing/Rehabilitation Covered 100% after plan deductible met Lifetime Maximum Out-Of-Network - Unlimited Facility Covered up to 180 days 10,000 maximum per calendar year Preventive Care Hospice Covered 100External Prosthetic Appliances l 00% after plan deductible met Pediatric Covered Outpatient Hospital Adult Covered Outpatient Surgery Covered 100% after plan deductible met Facility Charges (Prior Authorization Required) Hearing Covered Diagnostic Lab & X-ray Covered 100% after plan deductible met Screening part of physical exam Gynecological Covered Pre-Admission Testing Covered 100% after plan deductible met Medical Services Other Services Medical Office Visit Covered 100% after plan deductible met Durable Medical Equipment Covered 100% after plan deductible met Outpatient PT/OT/ST/Chiro. Covered 100% after plan deductible met Prosthetics Covered 100% after plan deductible met 60 Combined Days per calendar covered expenses Subject to deductible, coinsurance and R&C $5,000 maximum for prosthetic@ Calendar year per member replacement parts maximum $500 Home Health Care Covered 100% after of covered expenses with prior approval Subject to deductible, coinsurance and R&C Prescription Drugs $5 Generic $25 Brand Name $40 Non Formulary Brand Name Mail Order 90 Day Supply $l0 Generic $50 Preferred Brand $80 Non-Preferred Brand Name Emergency pharmacy services only Dependent/Student Eligibility To age 26 as per PPACA DENTAL AND OPTICAL The City will provide a PPO dental plan deductible met Allergy Services Covered as follows: City of Stamford – SPA Group #4529 - 0003 Delta Dental PPOSM plus Premier Effective November 1, 2016 Calendar Year Deductible  Per Person $50  Family Aggregate Maximum $100 Plan Pays: Preventive & Diagnostic (No Deductible) 100% after plan deductible met Unlimited days (Prior Authorization Required) Vision Covered 100% after plan deductible met Diagnostic Lab &  Exams, Cleanings, Bitewing X-ray Covered 100Rays (2 per calendar year per person)  Fluoride Treatment (For children to age 19) Remaining Basic (After Deductible) 80% after plan deductible met Covered once every 24 months Prescriptions Rx copays apply after the deductible is met  Fillings, Extractions, Root Canals (Endodontics)  Periodontal, Oral Surgery  Repair of Dentures  Sealants (To age 14) Crowns & Prosthodontics (After Deductible) 75%  Crowns, Gold Restorations  Bridgework, Full & Partial Dentures  Implants Calendar Year Maximum (Per Person) $5/$20/$35 Three Tier Formulary RX Rider Surgery Fees Covered 1002,000 Orthodontia (Dependent Children Only)  Coinsurance 50% after plan deductible met All benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a  Lifetime Maximum $5,000 lifetime maximum. Emergency Care ELIGIBILITY: 2,500 Dependent children are covered to age 26 26. Delta Dental has two networks available under this plan. The Delta Dental Premier® network is the largest of the Delta Dental networks with over 368,000 participating dentist offices nationally (80%+). Delta Dental PPO5M is a smaller, but more discounted network with over 293,000 participating dentist offices nationwide. Delta Dental PPO5M fees are on average 20% less than Delta Dental Premier®. You may use any fully licensed dentist under this plan, but it is to your advantage to use a network dentist, especially PPO, since they accept the Delta Dental allowance as their maximum charge and cannot xxxx Delta Dental patients for medical amounts above this level. Participating dentists will be paid directly by Delta Dental for covered services. Non-participating dentists will xxxx you directly, and Emergency Room Covered 100% after Delta Dental will make claim payment directly to you. You will maximize benefits and reduce paperwork by using a Delta Dental participating dentist. If you do not have a dentist, you may obtain a current listing of participating dentists in any area, by calling 1-800 DELTA OK (0-000-000-0000). Provide your zip code to the representative and a directory for that area will be mailed to your home. If you have Internet access, you may also visit our website at xxxxxxxxxxxxx.xxx to locateparticipating dentists. At the time of your first appointment, tell the dentist that you are covered under this program and provide your group number and ID number. Your dependents, if covered, should provide the employee's ID number. Claim questions and other information needs should be directed to Delta Dental's customer service department at 1-800-452-9310. This overview contains a general description of your dental care program for your use as a convenient reference. Complete details of your program appear in the group contract between your plan deductible met prescription planssponsor and Delta Dental of New Jersey, Inc. which governs the benefits and operation of your program. Urgent Care Covered 100% after plan deductible met Ambulance Covered 100% after plan deductible met Matrix CIGNA HDHPIn CT, Delta Dental Insurance Company writes dental coverage on an insured basis and Delta Dental of New Jersey administers self-HSA Res Sup 07/01/2020funded dental benefit programs. The group contract would control if there should be any inconsistency or difference between its provisions and the information in this overview.

Preventive Care. Pediatric No Copay No Copay Routine Well Adult No Copay No Copay Vision No Copay No Copay Care 100% 50% 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% 50% after deductible Includes: office visits, routine physical examination, laboratory tests, x-rays, immunizations, and other Preventive services as required by law. Flu Shot 100% Paid Same As Network Eye Exam (including refractive exams) 100% after deductible Limited to 1 per Calendar Year, unless otherwise required by law Not Covered once every 24 months Organ Transplants 100% after deductible Not Covered once every 24 months Hearing No Copay No Copay Screening part of physical exam Screening part of physical exam Gynecological No Copay No Copay Prescription Drugs (Mail Order or Retail Pharmacy) 100% after deductible Paid Same As Network Other Medical Services Medical Office Visit Copay Copay Outpatient PT/OT/ST/Chiroand Supplies 100% after deductible 80% 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 Products included on the Plan Select Drugs and Products List require prior authorization and enrollment in the Select Drugs and Products Program. Copay Copay MEDICAL BENEFITS SCHEDULE MINIMUM VALUE PLAN NETWORK PROVIDERS NON-NETWORK PROVIDERS Note: The maximums listed below are the total for Network and Non-Network expenses. For example, if a maximum of 60 Combined Days days is listed twice under a service, the Calendar Year maximum is 60 Combined Days per calendar year per member per calendar year per member Allergy Services office visits days total which may be split between Network and testing; Copay office visits and testing; Copay No copay Non-Network providers. DEDUCTIBLE, PER CALENDAR YEAR Per Covered Person $5,000 $10,000 Per Family Unit $10,000 $20,000 The Network Deductible amounts will be combined with the Non-Network Deductible amounts. The Calendar Year deductible is waived for injections No copay for injections Diagnostic Lab & Xthe following Covered Charges: - Network Preventive Care MAXIMUM OUT-ray OF-POCKET AMOUNT, PER CALENDAR YEAR (including deductibles) Per Covered Covered Inpatient Medical Services Covered Covered Surgery Fees Covered Covered Office Surgery Covered Covered Outpatient MH/SA Copay based on date of service Copay based on date of service Emergency Care Emergency Room Person $75 Copay (waived if admitted) 6,500 $75 Copay (waived if admitted) Sudden & Serious Guidelines Sudden & Serious Guidelines Urgent Care 13,000 Per Family Unit $25 Copay 13,000 $25 Copay Ambulance Covered Covered APPENDIX C Town of Manchester, Connecticut BENEFIT OAP Plus OAP Basic Inpatient Hospital General/Medical/Surgical/ Pre-cert only for 26,000 The Network Out-of-Pocket amounts will be combined with the Non-Network Maternity (Semi-private) $200 Copay Effective 7/1/2017 $200 Copay Effective 7/1/2017 Ancillary Services Covered Covered Medication, Supplies Psychiatric Unlimited days Unlimited days Substance Abuse/Detox Unlimited days Unlimited days Skilled Nursing/Rehabilitation Covered up to 180 days per calendar year Covered up to 180 days per calendar year Facility Hospice Covered Covered Outpatient Hospital Outpatient Surgery Facility Charges $100 Copay $100 Copay (Prior Authorization Required) (Prior Authorization Required) Diagnostic Lab & X-ray Covered Covered Pre-Admission Testing Covered Covered Other Services Durable Medical Equipment Covered Covered Prosthetics Covered Covered Home Health Care Unlimited days Unlimited days (Prior Authorization Required) (Prior Authorization Required) Pharmacy Benefits Prescriptions $5/$20/$35 $5/$20/$35 Unlimited maximum Unlimited maximum Three Tier Formulary RX Rider Three Tier Formulary RX Rider All Benefits listed are for In-Network. For Out-of-Network benefitsPocket amounts. The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum at which time the Plan will pay 100% of the remainder of Covered Charges for the OAP Plus 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 OAP Basic plans. ELIGIBILITY: Dependent children covered to age 26 Reasonable Charges Amounts for medical products included on the Select Drugs and prescription plans. APPENDIX C Town of Manchester, Connecticut BENEFIT High Deductible Health Plan/ BENEFIT High Deductible Health Plan/ Costshares Health Savings Account Products List COVERED CHARGES Inpatient Hospital Health Savings Account Deductible - $2,000/$4,000 General/Medical/Surgical/ Covered 100Services Room, Board, and Miscellaneous Expenses 50% after plan deductible met Coinsurance - 10050% after plan deductible met Maternity (Semi-private) for in network services $4,000/$8,000 out of pocket maximum Ancillary Services Covered 100% after plan deductible met Coinsurance - 80% after plan deductible met Medication, Supplies for out of network services Psychiatric Covered 100% after plan deductible met Employer Contribution Unlimited days $1,000 single coverage $2,000 double or family coverage Substance Abuse/Detox Covered 100% after plan deductible met Unlimited days Lifetime Maximum InNon-Network - Unlimited Skilled Nursing/Rehabilitation Covered 100% after plan deductible met Lifetime Maximum Out-Of-Network - Unlimited Facility Covered up to 180 days per calendar year Preventive Care Hospice Covered 100% after plan deductible met Pediatric Covered Outpatient Hospital Adult Covered Outpatient Surgery Covered 100% after plan deductible met Facility Charges (Prior Authorization Required) Hearing Covered Diagnostic Lab & X-ray Covered 100% after plan deductible met Screening part Inpatient admissions as a result of physical exam Gynecological Covered Pre-Admission Testing Covered 100% after plan deductible met Medical Services Other Services Medical Office Visit Covered 100% after plan deductible met Durable Medical Equipment Covered 100% after plan deductible met Outpatient PT/OT/ST/Chiro. Covered 100% after plan deductible met Prosthetics Covered 100% after plan deductible met 60 Combined Days per calendar year per member Home Health Care Covered 100% after plan deductible met Allergy Services Covered 100% after plan deductible met Unlimited days (Prior Authorization Required) Vision Covered 100% after plan deductible met Diagnostic Lab & X-ray Covered 100% after plan deductible met Covered once every 24 months Prescriptions Rx copays apply after the deductible is met $5/$20/$35 Three Tier Formulary RX Rider Surgery Fees Covered 100% after plan deductible met All benefits listed are for an emergency will be paid same as In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum. Emergency Care ELIGIBILITY: Dependent children covered to age 26 for medical and Emergency Room Covered 100% after plan deductible met prescription plans. Urgent Care Covered 100% after plan deductible met Ambulance Covered 100% after plan deductible met Matrix CIGNA HDHP-HSA Res Sup 07/01/2020.

Preventive Care. Pediatric No Copay No Copay Well Care, including immunizations (See page 37) $10 copayment Subject to deductible, coinsurance, and R&C Monthly - birth to 5 months of age Every other month - 6 months to 11 months of age Every 3 months - 12 months to 23 months of age Every 6 months - 24 months to 35 months of age Once per calendar year - age 3 through age 17 Adult No Copay No Copay Vision No Copay No Copay Covered Routine Physical Examinations $10 copayment Subject to deductible, coinsurance, and R&C Every 3 calendar years - age 18 to 29 Every other calendar year - age 30 to 49 Every calendar year - on or after age 50 Gynecological Routine Examinations $10 copayment Subject to deductible, coinsurance, and R&C Once per calendar year In addition - as medically necessary Mammographic Services $10 copayment Subject to deductible, coinsurance, and R&C Age 35 to 39 - one baseline mammography Age 40 and over-once every 24 months Covered once every 24 months calendar year or as medically necessary Hearing No Copay No Copay Screening part of physical exam Screening part of physical exam Gynecological No Copay No Copay Examinations $10 copayment Subject to deductible, coinsurance, and R&C Medical Services Medical Office Visit Copay Copay $10 copayment Subject to deductible, coinsurance, and R&C Outpatient PT/OT/ST/Chiro. Copay Copay 60 - Occupational, Physical and Speech Therapy $10 copayment Subject to deductible, coinsurance, and R&C Combined Days 60 Combined Days 30 visit maximum per calendar year per member * R&C - Reasonable and Customary Allowance BENEFITS IN-NETWORK OUT-OF-NETWORK Chiropractic Therapy $10 copayment Subject to deductible, coinsurance, and R&C 30 visit maximum per calendar year per member Allergy Services office visits $10 copayment Allergy shots including bee venom extract Office visit and testing; Copay office visits allergy shots combined subject to one copayment Subject to deductible, coinsurance, and testing; Copay No copay for injections No copay for injections R&C Diagnostic Lab & X-ray Covered Covered Ray and Chemotherapy Services 100% of covered expenses Subject to deductible, coinsurance, and R&C Inpatient - Medical Services Covered Covered 100% of covered expenses $100 copayment per admission Subject to deductible, coinsurance, and R&C Prior Authorization required for certain procedures Surgery Fees Covered Covered 100% of covered expenses Subject to deductible, coinsurance, and R&C Prior Authorization required for certain procedures Office Surgery Covered Covered $10 copayment Subject to deductible, coinsurance, and R&C Prior Authorization required for certain procedures Mental Health and Substance Abuse IN-NETWORK OUT-OF-NETWORK Inpatient Hospital Psychiatric Biologically Based 100% of covered expenses $100 copayment per admission Subject to deductible, coinsurance, and R&C Outpatient MH/SA Copay based on date Mental Health Biologically Based $10 copayment Subject to deductible, coinsurance, and R&C Inpatient Hospital Psychiatric Non-Biologically Based 100% of service Copay based on date covered expenses $100 copayment per admission Subject to deductible, coinsurance, and R&C 60 Inpatient day maximum or substitution for 120 partial hospitalization days per calendar year Outpatient Mental Health Non-Biologically Based $20 copayment 50% R&C 30 Outpatient Visits per calendar year Inpatient Hospital Substance Abuse and / or Alcoholism 100% of service covered expenses $100 copayment per admission Subject to deductible, coinsurance, and R&C Outpatient Substance Abuse and / or Alcoholism $10 copayment Subject to deductible, coinsurance, and R&C Combine inpatient and outpatient maximum of 45 days per calendar year Emergency Care Emergency Room $75 Copay (waived 50 copayment Waived if admitted) admitted $75 Copay (waived 50 copayment Waived if admitted) Sudden & Serious Guidelines Sudden & Serious Guidelines admitted After Hours Urgent Care Center $25 Copay 10 copayment $25 Copay 10 copayment Walk-In Center $10 copayment $10 copayment Ambulance Covered Covered APPENDIX C Town 100% of Manchestercovered expenses 100% of covered expenses When determined medically necessary Biologically-based mental illnesses include: Schizoaffective Disorder, Connecticut BENEFIT OAP Plus OAP Basic Major Depressive Disorder, Bi-Polar Disorder, Paranoia and other Psychotic Disorders, Obsessive-Compulsive Disorder, Panic Disorder, Pervasive Development Disorder, or Autism. BENEFITS IN-NETWORK OUT-OF-NETWORK Inpatient Hospital General/Medical/Surgical/ Pre-cert only for Out-of-Network Maternity (Semisemi-private) private)/ Intensive Care 100% of covered expenses $200 Copay Effective 7/1/2017 $200 Copay Effective 7/1/2017 100 copayment per admission Subject to deductible, coinsurance, and R&C Subject to non-emergency precertification Ancillary Services Covered Covered Medication(medication, Supplies Psychiatric Unlimited days Unlimited days Substance Abuse/Detox Unlimited days Unlimited days Skilled Nursing/Rehabilitation Covered up supplies) 100% of covered expenses Subject to 180 days per calendar year Covered up to 180 days per calendar year Facility Hospice Covered Covered deductible, coinsurance, and R&C Outpatient Hospital Outpatient Surgery - Surgery, Facility Charges $100 Copay $100 Copay (Prior Authorization Required) (Prior Authorization Required) 100% of covered expenses Subject to deductible, coinsurance, and R&C Diagnostic Lab & X-ray Covered Covered Ray 100% of covered expenses Subject to deductible, coinsurance, and R&C Pre-Admission Testing Covered Covered 100% of covered expenses Subject to deductible, coinsurance, and R&C Other Services Rehabilitation 100% of covered expenses Subject to deductible, coinsurance, and R&C 45 day maximum or substitution for hospitalization Skilled Nursing Facility 100% of covered expenses Subject to deductible, coinsurance, and R&C 60 day maximum per calendar year Hospice 100% of covered expenses 100% of covered expenses Individuals with life expectancy of 6 months or less Durable Medical Equipment Covered Covered Prosthetics Covered Covered Home Health Care Unlimited days Unlimited days (Prior Authorization Required) (Prior Authorization Required) Pharmacy Benefits Prescriptions $5/$20/$35 $5/$20/$35 Unlimited maximum Unlimited maximum Three Tier Formulary RX Rider Three Tier Formulary RX Rider All Benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum for the OAP Plus and OAP Basic plans. ELIGIBILITY: Dependent children covered to age 26 for medical and prescription plans. APPENDIX C Town of Manchester, Connecticut BENEFIT High Deductible Health Plan/ BENEFIT High Deductible Health Plan/ Costshares Health Savings Account Inpatient Hospital Health Savings Account Deductible - $2,000/$4,000 General/Medical/Surgical/ Covered 100% after plan deductible met Coinsurance - 100% after plan deductible met Maternity (Semi-private) for in network services $4,000/$8,000 out of pocket maximum Ancillary Services Covered 100% after plan deductible met Coinsurance - 80% after plan deductible met Medication, Supplies for out of network services Psychiatric Covered 100coinsurance 50% after plan deductible met Employer Contribution Unlimited days coinsurance $1,000 single coverage $2,000 double or family coverage Substance Abuse/Detox Covered 100% after plan deductible met Unlimited days Lifetime Maximum In-Network - Unlimited Skilled Nursing/Rehabilitation Covered 100% after plan deductible met Lifetime Maximum Out-Of-Network - Unlimited Facility Covered up to 180 days 10,000 maximum per calendar year Preventive Care Hospice Covered Prosthetics 100% after plan deductible met Pediatric Covered Outpatient Hospital Adult Covered Outpatient Surgery Covered 100% after plan deductible met Facility Charges (Prior Authorization Required) Hearing Covered Diagnostic Lab & X-ray Covered 100% after plan deductible met Screening part of physical exam Gynecological Covered Pre-Admission Testing Covered 100% after plan deductible met Medical Services Other Services Medical Office Visit Covered 100% after plan deductible met Durable Medical Equipment Covered 100% after plan deductible met Outpatient PT/OT/ST/Chiro. Covered 100% after plan deductible met Prosthetics Covered 100% after plan deductible met 60 Combined Days per calendar covered expenses Subject to deductible, coinsurance, and R&C $5,000 maximum for prosthetic Calendar year per member replacement parts maximum $500 Home Health Care Covered 100% after plan deductible met Allergy Services Covered 100% after plan deductible met Unlimited days of covered expenses with prior approval Subject to deductible, coinsurance, and R&C Prescription Drugs $5 Generic $10 Preferred Brand (Prior Authorization Required30 day max) Vision Covered 100% after plan deductible met Diagnostic Lab & X$5 mail order (90 day supply) no max Effective July 1, 2006 $10 Generic $20 Preferred Brand (30day max) $30 Non-ray Covered 100% after plan deductible met Covered once every 24 months Prescriptions Rx copays apply after the deductible is met Preferred Brand $5/$20/$35 Three Tier Formulary RX Rider Surgery Fees Covered 100% after plan deductible met All benefits listed are for In10 mail order (90-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. INFERTILITY: Coverage is subject to a $5,000 lifetime maximum. day supply) Emergency Care ELIGIBILITY: Dependent children covered to age 26 for medical and Emergency Room Covered 100% after plan deductible met prescription plans. Urgent Care Covered 100% after plan deductible met Ambulance Covered 100% after plan deductible met Matrix CIGNA HDHP-HSA Res Sup 07/01/2020pharmacy services only