Common use of Preventive Care Clause in Contracts

Preventive Care. Pediatric No Copay No Copay No Copay Deductible Waived-No Copay Age based schedule 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year Adult No Copay No Copay No Copay Deductible Waived-No Copay Age Based Schedule 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over- Preventative exams allowed once a year Immunizations As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam Gynelogical/Obstetrics $0 Copay for annual exam $0 Copay for annual exam $0 Copay for annual exam Deductible waived-$0 Copay for annual exam $25 Copay Maternity-First Visit Only $25 Copay Maternity-First Visit Only $20 Copay Maternity-First Visit Only After deductable 80% In Network Mammography Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening 40 and over once a year 40 and over once a year 40 and over once a year 40 and over once a year (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) Hearing No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived Vision No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived MEDICAL SERVICES Medical office visits $15 Copay PCP $15 Copay PCP $20 Copay After Deductible 80% Co-Insurance in $25 Specialist $25 Specialist Unlimited Visits network 60% Out of Network Physical or Occupational $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Therapy 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 60 Combined Visits for pt, ot st per member per year 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Speech Therapy $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Chiropractic Services $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro Allergy Services $25 Copay $25 Copay $20 Copay for office visit After Deductible 80% Co-Insurance in network 60% out of network 80 visits in 3 years 80 visits in 3 years Injections-20% after deductible 80 visits in 3 years 80 visits in 3 years Covered Covered Covered After Deductible Diagnostic, Lab & X-ray High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximum Outpatient Mental Health & $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Substance Abuse Unlimited Visits Unlimited Visits Unlimited Visits Unlimited Visits Prior auth required Prior auth required Prior auth required Prior auth required EMERGENCY CARE Emergency Room $100 Copay (waived if admitted) $100 Copay (waived if admitted) $100 Copay (waived if admitted) After Deductible 80% Co-Insurance in network 60% out of network Urgent Care $75 Copay $50 Copay $75 Copay After Deductible 80% Co-Insurance in network 60% out of network Walk-In Centers $15 Copay $15 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Ambulance Unlimited for Land and Air Unlimited for Land and Air 20% after deductible in or out of network After Deductible 80% Co-Insurance in network 60% out of network INPATIENT HOSPITAL- Inpatient- General/Medical/Surgical/ Maternity (Semi-Private) All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admission Require Pre-Cert 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Ancillary Services- Medications and Supplies Covered Covered 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Mental Health $250 Copay Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Biologically Based) Unlimited Days Unlimited Days Unlimited Days Mental Health $250 Copay Per Admission Copay $250 Copay Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Non-Biologically Based) Unlimited Days Unlimited Days Unlimited Days Unlimited Days Substance Abuse $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Unlimited Days Unlimited Days Unlimited Days Unlimited Days Rehabilitative Services $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 60 Days Per Calendar Year 60 Days Per Calendar Year 60 Days Per Calendar Year 100 Days Per Calendar Year Skilled Nursing Facility $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 120 Days Per calendar Year 120 Days Per calendar Year 120 Days Per calendar Year 100 Days Per calendar Year Outpatient Surgery Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required (Facility Charges) $200 Copay $200 Copay 20% after deductible up to the out of pocket maximum After Deductible 80% Co-Insurance in network 60% out of network Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) After Deductible 80% / 60% Pre-Admission Testing Covered Covered After Deductible 80% Co- Insurance in network 60% out of network After Deductible 80% Co-Insurance in network 60% out of network Diagnostic Lab & X-Ray Covered Covered Covered Prior Authorization Required High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximum

Preventive Care. Pediatric Well child care* No Copay Charge Deductible & Coinsurance Periodic, routine health examinations* No Copay Charge , Routine eye screenings — one exam even two calendar years OV Copayment Routine OB/GYN visits — one exam per year No Copay Deductible Waived-Charge Mammography* No Copay Age based schedule 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams 1-5 Charge Hearing screening — one exam every two calendar years 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year Adult No Copay No Copay No Copay Deductible Waived-No Copay Age Based Schedule 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over- Preventative exams allowed once a year Immunizations As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam Gynelogical/Obstetrics $0 Copay for annual exam $0 Copay for annual exam $0 Copay for annual exam Deductible waived-$0 Copay for annual exam $25 Copay Maternity-First Visit Only $25 Copay Maternity-First Visit Only $20 Copay Maternity-First Visit Only After deductable 80% In Network Mammography Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening 40 and over once a year 40 and over once a year 40 and over once a year 40 and over once a year (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) Hearing No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived Vision No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived OV Copayment MEDICAL SERVICES Medical CARE Primary care office visits $15 Copay PCP $15 Copay PCP $20 Copay After OV Copayment Deductible 80% Co& Coinsurance Specialist consultations OV Copayment OB/GYN care OV Copayment Maternity care — initial visit subject to copayment, no charge thereafter OV Copayment Laboratory No charge X-Insurance ray and Diagnostic Testing No charge Allergy Services Office visits/testing , Injections-80 within 33 ears OV Copayment No charge HOSPITAL CARE —Prior authorization required. Semi-private room NO Copayment Deductible & Coinsurance Maternity and newborn care NO Copayment NO Copayment Skilled nursing facility — up to 120 days per calendar year Rehabilitative services — up to 60 days per person per calendar year NO Copayment Outpatient surgery — in $25 Specialist $25 Specialist Unlimited Visits network 60% Out of Network Physical a hospital or Occupational $25 Copay $25 Copay $20 Copay After surgi-center NO Copayment EMERGENCY CARE Walk-in centers OV Copayment Deductible 80% Co-Insurance in network 60% out of network Therapy 30 Combined Visits & Coinsurance Urgent care — at participating centers only UR Copayment Not covered Emergency care — copayment waived if admitted ER Copayment ER Copayment Covered Ambulance Covered OTHER HEALTH CARE Outpatient rehabilitative services 60 Visit Maim= for pt, ot st PT. OE ST and Chiropractic services per member per calendar year 30 Combined Visits for ptNo Copayment Deductible & Coinsurance Prosthetic devices Unlimited Durable medical equipment Unlimited PRESCRIPTION DRUGS thru EXPRESS SCRIPTS Generic $5 retail up to 34 day supply No-copay, ot st mail order up to 100 day supply Listed Brand $10 retail up to 34 day supply No co-pay, mail order up to 100 day supply Maximum per member calendar year, per year 30 Combined Visits for ptperson. Cap thru ESI. Once cap is met, ot st per member per year 60 Combined Visits for ptsubmit to Anthem as 'out-of-network', ot st per member per year 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Speech Therapy subject to deductible & coinsurance $25 Copay 5,000 $25 Copay $20 Copay After Deductible 200 deductible, 80% Cocoinsurance MENTAL HEALTH/SUBSTANCE ABUSE CARE Inpatient -Unlimited Outpatient/office visits -Unlimited No charge OV Copayment Deductible & Coinsurance * Schedule of health examinations: AGE 0 UP TO AGE 1-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro7 VISITS AGE 1 UP TO AGE 5-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 7 VISITS AGE 5 UP TO AGE 12- I EVERY YEAR AGE 12 visit for chiro-prior auth is required on pt/ot Chiropractic Services $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro Allergy Services $25 Copay $25 Copay $20 Copay for office visit After Deductible 80% Co-Insurance in network 60% out of network 80 visits in 3 years 80 visits in 3 years Injections-20% after deductible 80 visits in 3 years 80 visits in 3 years Covered Covered Covered After Deductible Diagnostic, Lab & X-ray High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximum Outpatient Mental Health & $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Substance Abuse Unlimited Visits Unlimited Visits Unlimited Visits Unlimited Visits Prior auth required Prior auth required Prior auth required Prior auth required EMERGENCY CARE Emergency Room $100 Copay (waived if admitted) $100 Copay (waived if admitted) $100 Copay (waived if admitted) After Deductible 80% Co-Insurance in network 60% out of network Urgent Care $75 Copay $50 Copay $75 Copay After Deductible 80% Co-Insurance in network 60% out of network Walk-In Centers $15 Copay $15 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Ambulance Unlimited for Land and Air Unlimited for Land and Air 20% after deductible in or out of network After Deductible 80% Co-Insurance in network 60% out of network INPATIENT HOSPITAL- Inpatient- General/Medical/Surgical/ Maternity (Semi-Private) All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admission Require Pre-Cert 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Ancillary Services- Medications and Supplies Covered Covered 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Mental Health $250 Copay Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Biologically Based) Unlimited Days Unlimited Days Unlimited Days Mental Health $250 Copay Per Admission Copay $250 Copay Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Non-Biologically Based) Unlimited Days Unlimited Days Unlimited Days Unlimited Days Substance Abuse $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Unlimited Days Unlimited Days Unlimited Days Unlimited Days Rehabilitative Services $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 60 Days Per Calendar Year 60 Days Per Calendar Year 60 Days Per Calendar Year 100 Days Per Calendar Year Skilled Nursing Facility $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 120 Days Per calendar Year 120 Days Per calendar Year 120 Days Per calendar Year 100 Days Per calendar Year Outpatient Surgery Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required (Facility Charges) $200 Copay $200 Copay 20% after deductible up to the out of pocket maximum After Deductible 80% Co-Insurance in network 60% out of network Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) After Deductible 80% / 60% Pre-Admission Testing Covered Covered After Deductible 80% Co- Insurance in network 60% out of network After Deductible 80% Co-Insurance in network 60% out of network Diagnostic Lab & X-Ray Covered Covered Covered Prior Authorization Required High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximumUP TO AGE 22- 1 EVERY YEAR

Preventive Care. Pediatric No Copay No Copay No Copay Deductible Waived-No Copay Age based schedule 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year Adult No Copay No Copay No Copay Deductible Waived-No Copay Age Based Schedule 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over- over-Preventative exams allowed once a year Immunizations As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam GynelogicalGynecological/Obstetrics $0 Copay for annual exam $0 Copay for annual exam $0 Copay for annual exam Deductible waived-$0 Copay for annual exam $25 Copay Maternity-First Visit Only $25 Copay Maternity-First Visit Only $20 Copay Maternity-First Visit Only After deductable deductible 80% In Network Mammography Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening 40 and over once a year 40 and over once a year 40 and over once a year 40 and over once a year (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) Hearing No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived Vision No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived MEDICAL SERVICES Medical office visits $15 Copay PCP $15 Copay PCP $20 Copay After Deductible 80% Co-Co- Insurance in $25 Specialist $25 Specialist Unlimited Visits network 60% Out of Network Physical or Occupational $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Co- Insurance in network 60% out of network Therapy 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 60 Combined Visits for pt, ot st per member per year 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Speech Therapy $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Co- Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Chiropractic Services $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Co- Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro Allergy Services $25 Copay $25 Copay $20 Copay for office visit After Deductible 80% Co-Co- Insurance in network 60% out of network 80 visits in 3 years 80 visits in 3 years Injections-20% after deductible 80 visits in 3 years 80 visits in 3 years Covered Covered Covered After Deductible Diagnostic, Lab & X-ray High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Co- Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximum Outpatient Mental Health & $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Substance Abuse Unlimited Visits Unlimited Visits Unlimited Visits Unlimited Visits Prior auth required Prior auth required Prior auth required Prior auth required EMERGENCY CARE Emergency Room $100 Copay (waived if admitted) $100 Copay (waived if admitted) $100 Copay (waived if admitted) After Deductible 80% Co-Insurance in network 60% out of network Urgent Care $75 Copay $50 Copay $75 Copay After Deductible 80% Co-Insurance in network 60% out of network Walk-In Centers $15 Copay $15 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Ambulance Unlimited for Land and Air Unlimited for Land and Air 20% after deductible in or out of network After Deductible 80% Co-Insurance in network 60% out of network INPATIENT HOSPITAL- Inpatient- General/Medical/Surgical/ Maternity (Semi-Private) All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admission Require Pre-Cert 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Ancillary Services- Medications and Supplies Covered Covered 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Mental Health $250 Copay Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Biologically Based) Unlimited Days Unlimited Days Unlimited Days Mental Health $250 Copay Per Admission Copay $250 Copay Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Non-Biologically Based) Unlimited Days Unlimited Days Unlimited Days Unlimited Days Substance Abuse $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Unlimited Days Unlimited Days Unlimited Days Unlimited Days Rehabilitative Services $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 60 Days Per Calendar Year 60 Days Per Calendar Year 60 Days Per Calendar Year 100 Days Per Calendar Year Skilled Nursing Facility $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 120 Days Per calendar Year 120 Days Per calendar Year 120 Days Per calendar Year 100 Days Per calendar Year Outpatient Surgery Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required (Facility Charges) $200 Copay $200 Copay 20% after deductible up to the out of pocket maximum After Deductible 80% Co-Insurance in network 60% out of network Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) After Deductible 80% / 60% Pre-Admission Testing Covered Covered After Deductible 80% Co- Insurance in network 60% out of network After Deductible 80% Co-Insurance in network 60% out of network Diagnostic Lab & X-Ray Covered Covered Covered Prior Authorization Required High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximumnetwork

Preventive Care. Pediatric No Copay No Copay No Copay Deductible Waived-No Copay Age based schedule 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year Adult No Copay No Copay No Copay Deductible Waived-No Copay Age Based Schedule 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over- Preventative exams allowed once a year Immunizations As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam Gynelogical/Obstetrics $0 Copay for annual exam $0 Copay for annual exam $0 Copay for annual exam Deductible waived-$0 Copay for annual exam $25 Copay Maternity-First Visit Only $25 Copay Maternity-First Visit Only Vision $20 Copay Maternity-First Visit Only After deductable 80% In Network Mammography Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening 40 and over Covered once a year 40 and over once a year 40 and over once a year 40 and over once a year (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) Hearing every two years No Copay (Covered once every 2 calendar years) 24 months No Copay (Covered once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived Vision No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived MEDICAL SERVICES Medical office visits $15 Copay PCP $15 Copay PCP 24 months Hearing $20 Copay After Deductible 80% Co-Insurance in $25 Specialist $25 Specialist Unlimited Visits network 60% Out Covered once every two years No Copay Screening part of Network Physical or Occupational $25 physical exam No Copay $25 Screening part of physical exam Gynecological No Copay No Copay No Copay Medical Services Medical Office Visit $20 Copay After Deductible 80% Co-Insurance in network 60% out Copay based on date of network Therapy 30 service Copay based on date of service Outpatient PT/OT/ST Chiro. No Charge 60 Combined Visits for pt, ot st Days per calendar year per member Copay based on date of service 60 Combined Days per calendar year 30 Combined Visits for pt, ot st per member Copay based on date of service 60 Combined Days per calendar year 30 Combined Visits for pt, ot st per member per year 60 Combined Visits for pt, ot st per member per year 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Speech Therapy $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Chiropractic Services $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro Allergy Services $25 Copay $25 Copay $20 Copay for office visit After Deductible 80% Co-Insurance in network 60% out visits and testing No copay for injections Copay based on date of network 80 service (office visits in 3 years 80 testing No copay for injections Copay based on date of service for office visits in 3 years Injections-20% after deductible 80 visits in 3 years 80 visits in 3 years Covered Covered Covered After Deductible Diagnostic, and testing No copay for injections Diagnostic Lab & X-ray High Cost Diagnostic Covered Covered Covered Inpatient Medical Services Covered Covered Covered APPENDIX E HEALTH BENEFIT PLAN SUMMARIES (MRI, MRA, CAT, CTA, PET, SpectCONTINUED) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a EMPLOYEES HIRED PRIOR TO 7/1/2004 BENEFIT OAP Preferred $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximum 20 OAP Plus OAP Basic Surgery Fees Covered Covered Covered Office Surgery Covered Covered Covered Outpatient Mental Health & $25 Copay $25 Copay MH/SA $20 Copay After Deductible 80% Co-Insurance in network 60% out per visit Copay based on date of network Substance Abuse Unlimited Visits Unlimited Visits Unlimited Visits Unlimited Visits Prior auth required Prior auth required Prior auth required Prior auth required EMERGENCY CARE service per visit Copay based on date of service per visit Emergency Care Emergency Room $100 75 Copay (waived if admitted) Sudden and Serious guidelines $100 75 Copay (waived if admitted) Sudden & Serious Guidelines $100 75 Copay (waived if admitted) After Deductible 80% Co-Insurance in network 60% out of network Sudden & Serious Guidelines Urgent Care Ambulance $75 25 Copay Covered $50 25 Copay Covered $75 25 Copay After Deductible 80% Co-Insurance in network 60% out of network Walk-In Centers $15 Copay $15 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Ambulance Unlimited for Land and Air Unlimited for Land and Air 20% after deductible in or out of network After Deductible 80% Co-Insurance in network 60% out of network INPATIENT HOSPITAL- Inpatient- Covered Inpatient Hospital General/MedicalMedical/ Surgical/Surgical/ Maternity (Semi-Privateprivate) All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admissions Require cert only for Out-of-network Covered Pre-Cert cert only for Out-of-network Covered 100% through 6/30/2015 $250 Per Admission 100 Copay All Hospital Admission Require Pre-Cert 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Ancillary Services- Medications and Supplies Covered Covered 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Mental Health $250 Copay Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Biologically Based) Unlimited Days Unlimited Days Unlimited Days Mental Health $250 Copay Per Admission Copay $250 Copay Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Non-Biologically Based) Unlimited Days Unlimited Days Unlimited Days Unlimited Days Substance Abuse $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Unlimited Days Unlimited Days Unlimited Days Unlimited Days Rehabilitative Services $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 60 Days Per Calendar Year 60 Days Per Calendar Year 60 Days Per Calendar Year 100 Days Per Calendar Year Skilled Nursing Facility $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 120 Days Per calendar Year 120 Days Per calendar Year 120 Days Per calendar Year 100 Days Per calendar Year Outpatient Surgery Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required (Facility Charges) Effective 7/1/2015 $200 Copay Effective 7/1/2016 Covered 100% through 6/30/2015 $100 Copay Effective 7/1/2015 $200 Copay 20% after deductible Effective 7/1/2016 Ancillary Services Medication, supplies Covered Covered Covered Psychiatric Unlimited days Unlimited days Covered Substance Abuse/ Detox Unlimited days Unlimited days Unlimited days Skilled Nursing/Rehabilitation Facility Covered up to the out of pocket maximum After Deductible 80180 days per calendar year Covered up to 180 days per calendar year Covered up to 180 days per calendar year Hospice Covered Covered Covered Outpatient Hospital Outpatient Surgery Facility Charges $50 Copay Covered 100% Co-Insurance in network 60% out of network Ambulatory surgery (in a hospital setting) through 6/30/2015 $50 Copay Effective 7/1/2015 $100 Ambulatory surgery Copay Effective 7/1/2016 (in a hospital settingPrior Authorization Required) Covered 100% through 6/30/2015 $50 Copay Effective 7/1/2015 $100 Ambulatory surgery Copay Effective 7/1/2016 (in a hospital settingPrior Authorization Required) After Deductible 80% / 60% Diagnostic Lab & X-ray Covered Covered Covered Pre-Admission Testing Covered Covered After Deductible 80% Co- Insurance in network 60% Covered APPENDIX E HEALTH BENEFIT PLAN SUMMARIES (CONTINUED) EMPLOYEES HIRED PRIOR TO 7/1/2004 BENEFIT OAP Preferred $20 OAP Plus OAP Basic Other Services Durable Medical Equipment Covered Covered Covered Prosthetics Covered Covered Covered Home Health Care 200 days per calendar year Unlimited days (Prior Authorization Required) Unlimited days (Prior Authorization Required) Express Scripts Prescriptions $5/$15/$25 to $1,000 maximum Three Tier Formulary RX Rider excess covered out of network After Deductible 80% Co$5/$10/$20 through 6/30/2015 $5/$20/$35 Effective 7/1/2015 Unlimited maximum Three Tier Formulary RX Rider $5/$10/$20 through 6/30/2015 $5/$20/$35 Effective 7/1/2015 Unlimited maximum Three Tier Formulary RX Rider * All benefits listed are for In-Insurance Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. OAP Basic plan has no Out-of-Network benefit. ** All plans are Non-Gatekeeper. No referrals are required. No primary care physician is required. STATE MANDATES are excluded from the OAP Preferred $20 and OAP Plus plans but are included in network 60% out of network Diagnostic Lab & X-Ray Covered Covered Covered Prior Authorization Required High Cost Diagnostic (MRIthe OAP Basic plan. INFERTILITY: Coverage excludes GIFT, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth ZIFT and a $75 copay per service up is subject to a $375 requires prior auth 5,000 lifetime maximum for OAP Plus and a OAP Basic plans: Unlimited for OAP Preferred $20 plan. ELIGIBILITY: Dependent children to age 25 for ALL plans; effective July 1, 2010 dependent children covered to age 26 for medical and prescription plans due to the passing of the Health Care Reform Act of March 30, 2010. APPENDIX E HEALTH BENEFIT PLAN SUMMARIES EMPLOYEES HIRED ON OR AFTER 7/1/2004 BENEFIT OAP Plus OAP Basic Costshares In-Network services subject to copays Out-of-Network services subject to deductible and coinsurance; balance billing allowed $5 Office Visit Copay Effective through 6/30/2015 $15 Office Visit Copay Effective 7/1/2015 $20 Office Visit Copay Effective 7/1/2016 $75 copay per service up Emergency Room Copay Deductible - $250/$750 Coinsurance - 80% $1,500/$4,500 OOP Max Lifetime Maximum In-Network - Unlimited Lifetime Maximum Out-Of-Network - Unlimited In-Network services subject to a copays $375 requires prior auth and a 5 Office Visit Copay Effective through 6/30/2015 $15 Office Visit Copay Effective 7/1/2015 $20 Office Visit Copay Effective 7/1/2016 $75 copay per service up to a $375 After Deductible 80% CoEmergency Room Copay Lifetime Maximum In-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximumNetwork - Unlimited

Preventive Care. Pediatric Routine Preventive Care - (Routine well child care, routine OB/GYN care, routine health examinations) - unlimited No Copay No Copay No Copay Deductible Waived-No Copay Age based schedule 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year Adult No Copay No Copay No Copay Deductible Waived-No Copay Age Based Schedule 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over- Preventative exams allowed once a year Immunizations As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam Gynelogical/Obstetrics $0 Copay for annual exam $0 Copay for annual exam $0 Copay for annual exam Deductible waived-$0 Copay for annual exam $25 Copay Maternity-First Visit Only $25 Copay Maternity-First Visit Only $20 Copay Maternity-First Visit Only After deductable charge You pay 20% Plan pays 80% In Network Mammography Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening 40 and over once a year 40 and over once a year 40 and over once a year 40 and over once a year (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) After the deductible is met Mammograms No charge Hearing screenings No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived Vision No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived charge MEDICAL SERVICES Medical office CARE Office visits $15 30 Copay PCP $15 Copay PCP $20 Copay After Deductible You pay 20% Plan pays 80% Co-Insurance in After the deductible is met Specialist consultations $25 Specialist 45 Copay OB/GYN care $25 Specialist Unlimited Visits network 60% Out of Network Physical or Occupational 30 Copay Maternity care - initial visit subject to copayment, no charge thereafter $25 30 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Therapy 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 60 Combined Visits for pt, ot st per member per year 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Speech Therapy $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Chiropractic Services $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro Allergy Services $25 Copay $25 Copay $20 Copay for office visit After Deductible 80% Co-Insurance in network 60% out of network 80 visits in 3 years 80 visits in 3 years Injections-20% after deductible 80 visits in 3 years 80 visits in 3 years Covered Covered Covered After Deductible Diagnostic, Lab & and X-ray High Cost Diagnostic cost diagnostics (MRI, MRA, includes CAT, CTA, PET, Spect) High Cost Diagnostic (MRISPECT, MRA, CAT, CTA, PET, SpectMRI) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximum Outpatient Mental Health & $25 Copay $25 100 Copay Allergy Services Office visits/testing $20 30 Copay After Deductible In Network You Pay: Out-of-Network You pay: Injections No charge HOSPITAL CARE - Prior authorization required. Semi-private room $400 You pay 20% Plan pays 80% CoAfter the deductible is met Maternity and newborn care $400 Skilled nursing facility, Rehabilitation Hospital, Sub-Insurance Acute Facilities - up to 180 days per calendar year $400 Outpatient surgery - in network 60% out of network Substance Abuse Unlimited Visits Unlimited Visits Unlimited Visits Unlimited Visits Prior auth required Prior auth required Prior auth required Prior auth required a hospital or surgi-center $200 EMERGENCY CARE Emergency Room Walk-in centers $100 Copay (waived if admitted) $100 Copay (waived if admitted) $100 Copay (waived if admitted) After Deductible 80% Co-Insurance in network 60% out of network Urgent Care $75 50 Copay $50 Copay Urgent care $75 50 Copay $50 Copay Hospital emergency room - copayment waived if admitted $150 Copay $150 Copay Ambulance $50 Copay $50 Copay OTHER HEALTH CARE Outpatient rehabilitative services: 50 days maximum for PT, OT, ST and Chiro. per year, excess covered as in network deductible and co-insurance Cardiac Rehab - unlimited days per calendar year Pulmonary rehab - unlimited days per calendar year Cognitive therapy -unlimited days per calendar year No charge after $30 per office visit Copay for 1st 50 days After Deductible 50 days, You pay 20% Plan pays 80% Co-Insurance in network 60After the deductible is met No charge No charge after $30 per office visit Copay You pay 20% out of network Walk-In Centers $15 Copay $15 Copay $20 Copay After Deductible Plan pays 80% CoAfter the deductible is met Prosthetic devices No charge You pay 20% Plan pays 80% After the deductible is met Durable medical equipment No charge You pay 20% Plan pays 80% After the deductible is met Hospice Care No charge You pay 20% Plan pays 80% After the deductible is met Home Health Care unlimited days per cal year No charge You pay 20% Plan pays 80% After the $50 deductible is met Routine eye exams - Coverage under CIGNA Vision Care Network - 1 exam annually No charge Coinsurance Plan reimburses 80% to maximum of $170 In Network You Pay: Out-Insurance in network 60of-Network You pay: MENTAL HEALTH/SUBSTANCE ABUSE CARE Inpatient $400 You pay 20% out of network Ambulance Unlimited for Land and Air Unlimited for Land and Air Plan pays 80% After the deductible is met Outpatient physician office visits $30 Copay Outpatient facility visits No charge PRESCRIPTION BENEFITS* Retail Generic $10 20% after deductible in or out of network After Deductible 80% CoRetail Brand Formulary $25 Retail Brand Non-Insurance in network 60% out of network INPATIENT HOSPITAL- Inpatient- General/Medical/Surgical/ Maternity (SemiFormulary $40 Mail Order Generic $20 Mail Order Brand Formulary $50 Mail Order Brand Non-Private) All Hospital Admissions Require Pre-Cert Formulary $250 Per Admission Copay All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admission Require Pre-Cert 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% 80 Pharmacy Out of Network Ancillary Services- Medications Pocket maximum $2000 Prescription Annual maximum Unlimited *Assumes mandatory generic substitution Note: In situations where the member is responsible for obtaining the necessary pre-certification or prior authorization and Supplies Covered Covered 20% after deductible up fails to do so, benefits may be reduced or denied. This summary outlines some highlights of your plan. For a complete list of both covered and not covered services, see your employer’s summary plan description -the official plan document. If there are any differences between this summary and the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% plan document, the information in Network 60% Out of Network Mental Health $250 Copay Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Biologically Based) Unlimited Days Unlimited Days Unlimited Days Mental Health $250 Copay Per Admission Copay $250 Copay Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Non-Biologically Based) Unlimited Days Unlimited Days Unlimited Days Unlimited Days Substance Abuse $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Unlimited Days Unlimited Days Unlimited Days Unlimited Days Rehabilitative Services $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 60 Days Per Calendar Year 60 Days Per Calendar Year 60 Days Per Calendar Year 100 Days Per Calendar Year Skilled Nursing Facility $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 120 Days Per calendar Year 120 Days Per calendar Year 120 Days Per calendar Year 100 Days Per calendar Year Outpatient Surgery Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required (Facility Charges) $200 Copay $200 Copay 20% after deductible up to the out of pocket maximum After Deductible 80% Co-Insurance in network 60% out of network Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) After Deductible 80% / 60% Pre-Admission Testing Covered Covered After Deductible 80% Co- Insurance in network 60% out of network After Deductible 80% Co-Insurance in network 60% out of network Diagnostic Lab & X-Ray Covered Covered Covered Prior Authorization Required High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximumplan document takes precedence. APPENDIX G

Preventive Care. Pediatric No Copay No Copay No Copay Deductible Waived-No Copay Age based schedule 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year Adult No Copay No Copay Vision No Copay Deductible Waived-Covered once every 24 months No Copay Age Based Schedule 22 and over-Preventative exams allowed Covered once a year 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over- Preventative exams allowed once a year Immunizations As every 24 months Hearing No Copay Screening part of Preventative Exam As physical exam No Copay Screening part of Preventative Exam As part of Preventative Exam As part of Preventative Exam Gynelogical/Obstetrics $0 physical exam Gynecological No Copay for annual exam $0 No Copay for annual exam $0 Copay for annual exam Deductible waived-$0 Copay for annual exam $25 Copay Maternity-First Medical Services Medical Office Visit Only $25 Copay Maternity-First Visit Only $20 Copay Maternity-First Visit Only After deductable 80% In Network Mammography Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening 40 and over once a year 40 and over once a year 40 and over once a year 40 and over once a year (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) Hearing No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived Vision No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived MEDICAL SERVICES Medical office visits $15 Copay PCP $15 Copay PCP $20 Copay After Deductible 80% Co-Insurance in Outpatient PT/OT/ST/Chiro. $25 Specialist 20 Copay 60 Combined Days per calendar year per member $25 Specialist Unlimited Visits network 60% Out of Network Physical or Occupational 20 Copay 60 Combined Days per calendar year per member Allergy Services $20 Copay for office visits and testing No copay for injections $20 Copay for office visits and testing No copay for injections Inpatient Medical Services $200 Hospital Admission Copay $200 Hospital Admission Copay BENEFIT OAP Plus $20 OAP Basic Surgery Fees Inpatient: $200 Hospital Admission Copay Outpatient: $100 Copay Inpatient: $200 Hospital Admission Copay Outpatient: $100 Copay Medical Services (cont.) Office Surgery $20 Copay $20 Copay Outpatient MH/SA $20 Copay $20 Copay Emergency Care Emergency Room $75 Copay (waived if admitted) Sudden & Serious Guidelines $75 Copay (waived if admitted) Sudden & Serious Guidelines Urgent Care $25 Copay $25 Copay Ambulance Covered Covered Inpatient Hospital General/Medical/Surgical Maternity (Semi-private) Pre-cert only for Out-of-network $20 200 Hospital Admission Copay After Deductible 80% CoPre-Insurance in cert only for Out-of-network 60% out of network Therapy 30 Combined Visits for pt$200 Hospital Admission Copay Ancillary Services Medication, ot st per member per year 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 60 Combined Visits for pt, ot st per member per year 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Speech Therapy Supplies $25 200 Hospital Admission Copay $25 200 Hospital Admission Copay Psychiatric $200 Hospital Admission Copay Unlimited days $200 Hospital Admission Copay Unlimited days Substance Abuse/Detox $200 Hospital Admission Copay Unlimited days $200 Hospital Admission Copay Unlimited days Skilled Nursing/ Rehabilitation Facility $200 Hospital Admission Copay Covered up to 180 days per calendar year $200 Hospital Admission Copay Covered up to 180 days per calendar year Hospice $200 Hospital Admission Copay $20 200 Hospital Admission Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Outpatient Hospital Outpatient Surgery Facility Charges (Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Chiropractic Services Authorization Required) $25 100 Copay (Prior Authorization Required) $25 100 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro Allergy Services $25 Copay $25 Copay $20 Copay for office visit After Deductible 80% Co-Insurance in network 60% out of network 80 visits in 3 years 80 visits in 3 years Injections-20% after deductible 80 visits in 3 years 80 visits in 3 years Covered Covered Covered After Deductible Diagnostic, Diagnostic Lab & X-ray High Cost Diagnostic Covered Covered Pre-Admission Testing Covered Covered Other Services Durable Medical Equipment Covered Covered Prosthetics Covered Covered Home Health Care Unlimited days (MRIPrior Authorization Required) Unlimited days (Prior Authorization Required) BENEFIT OAP Plus $20 OAP Basic Express Scripts Prescriptions $5/$20/$35 to unlimited maximum Three Tier Formulary RX Rider $5/$20/$35 to unlimited maximum Three Tier Formulary RX Rider * All benefits listed are for In-Network. For Out-of-Network benefits, MRAplease refer to your Employee Benefit Summary. ** All plans are Non-Gatekeeper. No referrals are required. No primary care physician is required. *** OAP Basic plan has no Out-of-Network benefit. STATE MANDATES are excluded from the OAP Plus $20, CATbut are included in the OAP Basic. Effective 7/1/15, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires State Mandates enacted prior auth and a to 1/1/15 are included in the OAP Plus $75 copay per service up 20 plan. INFERTILITY: Coverage is subject to a $375 requires prior auth 5,000 lifetime maximum for OAP Plus $20 and a OAP Basic. ELIGIBILITY: Dependent children to age 25 for ALL plans; effective July 1, 2010, dependent children covered to age 26 for medical and prescription due to the passing of the Health Care Reform Act of March 30, 2010. APPENDIX J EFFECTIVE 7/1/15 HIGH DEDUCTIBLE HEALTH PLAN BENEFIT High Deductible Health Plan Costshares Deductible - $75 copay per service up to a 2,000/$4,000 Coinsurance - 100% after plan deductible met for in network services $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 4,000/$8,000 out of pocket maximum Coinsurance - 80% Co-Insurance in network 60% after plan deductible met for out of network services Lifetime Maximum In-Network - Unlimited Lifetime Maximum Out-Of-Network - Unlimited Preventive Care Pediatric Covered Adult Covered Hearing Covered Screening part of physical exam Gynecological Covered Medical Services Medical Office Visit Covered 100% after plan deductible met Outpatient PT/OT/ST/Chiro. Covered 100% after plan deductible met 60 Combined Days per calendar year maximum calendar year maximum calendar year maximum per member Allergy Services Covered 100% after plan deductible met Diagnostic Lab & X-ray Covered 100% after plan deductible met Inpatient Medical Services Covered 100% after plan deductible met Surgery Fees Covered 100% after plan deductible met Office Surgery Covered 100% after plan deductible met Outpatient Mental MH/SA Covered 100% after plan deductible met BENEFIT High Deductible Health & $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Substance Abuse Unlimited Visits Unlimited Visits Unlimited Visits Unlimited Visits Prior auth required Prior auth required Prior auth required Prior auth required EMERGENCY CARE Plan Emergency Care Emergency Room $100 Copay (waived if admitted) $100 Copay (waived if admitted) $100 Copay (waived if admitted) After Deductible 80Covered 100% Co-Insurance in network 60% out of network after plan deductible met Urgent Care $75 Copay $50 Copay $75 Copay After Deductible 80% Co-Insurance in network 60% out of network Walk-In Centers $15 Copay $15 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Ambulance Unlimited for Land and Air Unlimited for Land and Air 20Covered 100% after plan deductible in or out of network After Deductible 80met Ambulance Covered 100% Co-Insurance in network 60% out of network INPATIENT HOSPITAL- Inpatient- after plan deductible met Inpatient Hospital General/Medical/Surgical/ Maternity (Semi-Privateprivate) All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admissions Require Precert only for Out-Cert $250 Per Admission Copay All Hospital Admission Require Preof-Cert 20Network Covered 100% after plan deductible met Ancillary Services Medication, Supplies Covered 100% after plan deductible met Psychiatric Covered 100% after plan deductible met Unlimited days Skilled Nursing/Rehabilitation Facility Covered 100% after plan deductible met Covered up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Ancillary Services- Medications and Supplies 180 days per calendar year Hospice Covered Covered 20100% after plan deductible up to the out of pocket maximum All met Outpatient Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Mental Health $250 Copay Per Admission Copay $250 Per Admission Copay 20Outpatient Surgery Facility Charges Covered 100% after plan deductible up to the out of pocket maximum All Hospital Admissions Require Premet (Prior Authorization Required) Diagnostic Lab & X-Cert After Deductable 80% in Network 60% Out of Network (Biologically Based) Unlimited Days Unlimited Days Unlimited Days Mental Health $250 Copay Per Admission Copay $250 Copay Per Admission Copay 20ray Covered 100% after plan deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Non-Biologically Based) Unlimited Days Unlimited Days Unlimited Days Unlimited Days Substance Abuse $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Unlimited Days Unlimited Days Unlimited Days Unlimited Days Rehabilitative Services $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 60 Days Per Calendar Year 60 Days Per Calendar Year 60 Days Per Calendar Year 100 Days Per Calendar Year Skilled Nursing Facility $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 120 Days Per calendar Year 120 Days Per calendar Year 120 Days Per calendar Year 100 Days Per calendar Year Outpatient Surgery Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required (Facility Charges) $200 Copay $200 Copay 20% after deductible up to the out of pocket maximum After Deductible 80% Co-Insurance in network 60% out of network Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) After Deductible 80% / 60% met Pre-Admission Testing Covered 100% after plan deductible met Other Services Durable Medical Equipment Covered After Deductible 80100% Co- Insurance in network 60after plan deductible met Prosthetics Covered 100% out of network After Deductible 80after plan deductible met Home Health Care Covered 100% Co-Insurance in network 60% out of network Diagnostic Lab & X-Ray Covered Covered Covered after plan deductible met Unlimited days (Prior Authorization Required Required) Vision Covered 100% after plan deductible met Covered once every 24 months BENEFIT High Cost Diagnostic (MRIDeductible Health Plan Prescriptions After plan deductible is met applicable Rx copays will apply: $5/$10/$20 Three Tier Formulary RX Rider * All benefits listed are for In-Network. For Out-of-Network benefits, MRAplease refer to your Employee Benefit Summary. ** Plan is Non-Gatekeeper. No referrals are required. No primary care physician is required. STATE MANDATES enacted prior to 1/1/15 are included. ELIGIBILITY: Dependent children to age 25 for ALL plans; effective July 1, CAT2010, CTAdependent children covered to age 26 for medical and prescription due to the passing of the Health Care Reform Act of March 30, PET2010. Employees may obtain additional information concerning benefits by going to the following section of the Town’s website: xxxx://xxx.xxxxxxxxxxxxxxxx.xxx/hrd/assets/File/Accessing%20Your%20Benefits%20Online%20 flyer(4).pdf The page is titled "Accessing Your Benefits on Line" and includes directions to go to xxxxxxx.xxx, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth xxxxxxxxxxxxxx.xxx and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximumxxxxxxxxxxxxx.xxx.

Preventive Care. Pediatric No Copay No Copay No Copay Deductible Waived-No Copay Age based schedule 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year Adult No Copay No Copay No Copay Deductible Waived-No Copay Age Based Schedule 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over- Preventative exams allowed once a year Immunizations As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam Gynelogical/Obstetrics $0 Copay for annual exam $0 Copay for annual exam $0 Copay for annual exam Deductible waived-$0 Copay for annual exam $25 Copay Maternity-First Visit Only $25 Copay Maternity-First Visit Only $20 Copay Maternity-First Visit Only After deductable 80deductible 90% In Network Mammography Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening 40 and over once a year 40 and over once a year 40 and over once a year 40 and over once a year (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Availableif Recommended by Doctor) Hearing No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived Vision No Copay (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived MEDICAL SERVICES Medical office visits $15 Copay PCP $15 Copay PCP $20 Copay ($15 if EPHC for PCP) After Deductible 8090% Co-Insurance in $25 Specialist $25 Specialist Unlimited Visits network Network 60% Out of Network Physical or Occupational $25 Copay $25 Copay $20 Copay After Deductible 80% Co90%Co-Insurance lnsurance in network 60% out of network Therapy 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 60 Combined Visits for pt, ot st per member per year 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Speech Therapy $25 Copay $25 Copay $20 Copay After Deductible 8090% Co-Co- Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Chiropractic Services $25 Copay $25 Copay $20 Copay After Deductible 80% Co90%Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro Allergy Services $25 Copay $25 Copay $20 Copay for office visit After Deductible 8090% Co-Co- Insurance in network 60% out 60%out of network 80 visits in 3 years 80 visits in 3 years Injections-20% after deductible 80 visits in 3 years 80 visits in 3 years Covered Covered Covered After Deductible Diagnostic, Lab & X-ray High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRIDiagnostic(MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 8090% Co-Co- Insurance in network 60network60% out of network calendar year maximum calendar year maximum calendar year maximum Outpatient Mental Health Health& Substance Abuse $25 Copay $25 Copay $20 Copay After Deductible 8090% Co-Co- Insurance in network 60% out of network Substance Abuse Unlimited Visits Unlimited Visits Unlimited Visits Unlimited Visits Prior auth required Prior auth required Prior auth required Prior auth required EMERGENCY CARE Emergency Room $100 Copay (waived if admitted) $100 Copay (waived if admitted) $100 Copay (waived if admitted) After Deductible 80% Co90%Co-Insurance in network 60% out of network Urgent Care $75 Copay $50 Copay $75 Copay After Deductible 8090% Co-Co- Insurance in network 60network60% out of network Walk-In Centers $15 Copay $15 Copay $20 Copay After Deductible 8090% Co-Co- Insurance in network 60network60% out of network Ambulance Unlimited for Land and Air Unlimited for Land and Air 20% after deductible in or out of network After Deductible 8090% Co-Co- Insurance in network 60network60% out of network INPATIENT HOSPITAL- Inpatient- General/Medical/Surgical/ Maternity (Semi-Private) All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admission Require Pre-Cert 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80CertAfter Deductible 90% in Network inNetwork 60% Out of Network Ancillary Services- Medications and Supplies Covered Covered 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80CertAfter Deductible 90% in Network inNetwork 60% Out of Network Mental Health $250 Copay Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80CertAfter Deductible 90% in Network inNetwork 60% Out of Network (Biologically Based) Unlimited Days Unlimited Days Unlimited Days Mental Health $250 Copay Per Admission Copay $250 Copay Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80CertAfter Deductible 90% in Network inNetwork 60% Out of Network (Non-Biologically Based) Unlimited Days Unlimited Days Unlimited Days Unlimited Days Substance Abuse $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80CertAfter Deductible 90% in Network inNetwork 60% Out of Network Unlimited Days Unlimited Days Unlimited Days Unlimited Days Rehabilitative Services $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80Deductible 90% in Network 60% Out of Network 60 Days Per Calendar Year 60 Days Per Calendar Year 60 Days Per Calendar Year 100 Days Per Calendar Year Skilled Nursing Facility $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80Deductible 90% in Network inNetwork 60% Out of Network 120 Days Per calendar Year 120 Days Per calendar Year 120 Days Per calendar Year 100 Days Per calendar Year Outpatient Surgery Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required (Facility Charges) $200 Copay $200 Copay 20% after deductible up to the out of pocket maximum After Deductible 80% Co90%Co-Insurance in network 60% out of network Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) After Deductible 8090% / 60% Pre-Admission Testing Covered Covered After Deductible 80% Co- Co-Insurance in network 60% out of network After Deductible 8090% Co-Insurance in network 60% out of network Diagnostic Lab & X-Ray Covered Covered Covered Prior Authorization Required High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRIDiagnostic(MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 8090% Co-Co- Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximummaximum OTHER SERVICES Durable Medical Equipment Covered at 100% In Network Covered at 100% Covered at 80% after deductible Covered at 50% after deductible is met (Including Prosthetics) Out Ntwrk - Deductible andCo- Insurance Home Health Care Covered Covered Deductible waived After Deductible 90% Co- Insurance in network60% out of network 200 Visits 200 Visits Covered at 80% in and out of network up to the out of pocket maximum 100 Days Per Calendar Year OON-$50 Deductible & 20% Coinsurance 200 Visits Hospice Covered up to Last 6 Months of Life Covered up to Last 6 Months of Life Covered up to Last 6 Months of Life Covered up to Last 6 Months of Life After Deductible 80% Co-Insurance in network 60% out of network After Deductible 90%Co-Insurance in network 60% out of network Acupuncture Not Covered Not Covered Not Covered Not Covered Orthotics $50 Co-Pay $50 Co-Pay $50 Co-Pay After Deductible 90%Co- Insurance in network, 60% out of network TMJ Not Covered Not Covered Not Covered Not Covered Gastric Bypass Not Covered Not Covered Not Covered Not Covered Infertility $25 Office Visit Copay $25 Office Visit Copay After Deductible 80% Co-Insurance in network 60% out of network After Deductible 90% Co- Insurance in network60% out of network State Mandate Level-Prior Auth required State Mandate Level-Prior Auth required State Mandate Level-Prior Auth required State Mandate Level- Prior Auth required Some Restrictions May Apply Some Restrictions May Apply Some Restrictions May Apply Some Restrictions MayApply $10/$25/$40 $10/$25/$40 $10/$25/$40 After deductible-$10/$25/$40 Drug Rider Mail order $10/$25/$40 Mail order $10/$25/$40 Mail order $10/$25/$40 Mail order $10/$25/$40 30/90 day supply 30/90 day supply 30/90 day supply 30/90 day supply Mandatory Generic and Mail order Mandatory Generic and Mail order Mandatory Generic and Mail order Mandatory Generic *The Student age for all three plans is 26/26. *This does not constitute the actual health plan or insurance policy. It is only a general description of the plan. Managed Three Tier Drug Rider Network Access to over 680 Pharmacies in CT Access to over 651000 pharmacies nationwide Participating Pharmacy Retail Copay-Generic $10.00 Listed Brand Copay $25.00 Non-Listed Brand Copay $40.00 Non-Participating Pharmacy Deductible $0.00 Co-insurance* 20% Supply Limits Retail 30 day - 1 copay Mail Order Copays 31-90 day supply-1 copay on generic or brand Mail Order Program

Preventive Care. Pediatric No Copay No Copay No Copay Deductible Waived-No Copay Age based schedule 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams Birth to One 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 7 exams 1-5 years 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year 5 -22 years-Preventative exams allowed once a year Adult No Copay No Copay Vision No Copay Deductible Waived-Covered once every 24 months No Copay Age Based Schedule 22 and over-Preventative exams allowed Covered once a year 22 and over-Preventative exams allowed once a year 22 and over-Preventative exams allowed once a year 22 and over- Preventative exams allowed once a year Immunizations As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam As part of Preventative Exam Gynelogical/Obstetrics $0 Copay for annual exam $0 Copay for annual exam $0 Copay for annual exam Deductible waived-$0 Copay for annual exam $25 Copay Maternity-First Visit Only $25 Copay Maternity-First Visit Only $20 Copay Maternity-First Visit Only After deductable 80% In Network Mammography Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening Age 35-39 Base Line Screening 40 and over once a year 40 and over once a year 40 and over once a year 40 and over once a year (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) (Add'l Exams Available if Recommended by Doctor) every 24 months Hearing No Copay (once every 2 calendar years) Screening part of physical exam No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) Screening part of physical exam Gynecological No Copay (once every 2 calendar years) Deductible Waived Vision No Copay Medical Services Medical Office Visit Copay based on date of service Copay based on date of service Outpatient PT/OT/ST Chiro. Copay based on date of service 60 Combined Days per calendar year per member Copay based on date of service 60 Combined Days per calendar year per member Allergy Services Copay based on date of service (once every 2 calendar years) No Copay (once every 2 calendar years) $0 Copay (once a every 2 years) No Copay (once every 2 calendar years) Deductible Waived MEDICAL SERVICES Medical office visits $15 testing No copay for injections Copay PCP $15 Copay PCP $20 Copay After Deductible 80% Co-Insurance in $25 Specialist $25 Specialist Unlimited Visits network 60% Out based on date of Network Physical or Occupational $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Therapy 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 30 Combined Visits for pt, ot st per member per year 60 Combined Visits for pt, ot st per member per year 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Speech Therapy $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro-prior auth is required on pt/ot Chiropractic Services $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 30 Combined Visits for pt, ot st 60 Combined Visits for pt, ot st 20 visit for chiro 20 visit for chiro-prior auth is required on pt/ot 20 visit for chiro-Prior auth required on pt/ot 12 visit for chiro Allergy Services $25 Copay $25 Copay $20 Copay service for office visit After Deductible 80% Co-Insurance in network 60% out of network 80 visits in 3 years 80 visits in 3 years Injections-20% after deductible 80 visits in 3 years 80 visits in 3 years Covered Covered Covered After Deductible Diagnostic, and testing No copay for injections Diagnostic Lab & X-ray High Cost Diagnostic Covered Covered Inpatient Medical Services Covered Covered Surgery Fees Covered Covered APPENDIX E HEALTH BENEFIT PLAN SUMMARIES (MRI, MRA, CAT, CTA, PET, SpectCONTINUED) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay EMPLOYEES HIRED ON OR AFTER 7/1/2004 BENEFIT OAP Plus OAP Basic Office Surgery Covered Covered Outpatient MH/SA Copay based on date of service per visit Copay based on date of service up to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year maximum Outpatient Mental Health & $25 Copay $25 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Substance Abuse Unlimited Visits Unlimited Visits Unlimited Visits Unlimited Visits Prior auth required Prior auth required Prior auth required Prior auth required EMERGENCY CARE visit Emergency Care Emergency Room $100 75 Copay (waived if admitted) Sudden & Serious Guidelines $100 75 Copay (waived if admitted) Sudden & Serious Guidelines Urgent Care Ambulance $25 Copay Covered $25 Copay Covered Inpatient Hospital General/Medical/ Surgical/Maternity (Semi-private) Pre-cert only for Out-of-network Covered 100% through 6/30/2015 $100 Copay Effective 7/1/2015 $200 Copay Effective 7/1/2016 Covered 100% through 6/30/2015 $100 Copay Effective 7/1/2015 $200 Copay Effective 7/1/2016 Ancillary Services Medication, supplies Covered Covered Psychiatric Unlimited days Covered Substance Abuse/ Detox Unlimited days Unlimited days Skilled Nursing/Rehabilitation Facility Covered up to 180 days per calendar year Covered up to 180 days per calendar year Hospice Covered Covered Outpatient Hospital Outpatient Surgery Facility Charges Covered 100% through 6/30/2015 $50 Copay Effective 7/1/2015 $100 Copay Effective 7/1/2016 (waived if admittedPrior Authorization Required) After Covered 100% through 6/30/2015 $50 Copay Effective 7/1/2015 $100 Copay Effective 7/1/2016 (Prior Authorization Required) Diagnostic Lab & X-ray Covered Covered Pre-Admission Testing Covered Covered Other Services Durable Medical Equipment Covered Covered Prosthetics Covered Covered APPENDIX E HEALTH BENEFIT PLAN SUMMARIES (CONTINUED) EMPLOYEES HIRED ON OR AFTER 7/1/2004 BENEFIT OAP Plus OAP Basic Home Health Care Unlimited days (Prior Authorization Required) Unlimited days (Prior Authorization Required) Express Scripts Prescriptions $5/$10/$20 through 6/30/2015 $5/$20/$35 Effective 7/1/2015 Unlimited maximum Three Tier Formulary RX Rider $5/$10/$20 through 6/30/2015 $5/$20/$35 Effective 7/1/2015 Unlimited maximum Three Tier Formulary RX Rider * All benefits listed are for In-Network. For Out-of-Network benefits, please refer to your Employee Benefit Summary. OAP Basic plan has no Out-of-Network benefit. ** All plans are Non-Gatekeeper. No referrals are required. No primary care physician is required. STATE MANDATES are excluded from the OAP Preferred $20 and OAP Plus plans but are included in the OAP Basic plan. INFERTILITY: Coverage excludes GIFT, ZIFT and is subject to a $5,000 lifetime maximum for OAP Plus and OAP Basic plans: Unlimited for OAP Preferred $20 plan. ELIGIBILITY: Dependent children to age 25 for ALL plans; effective July 1, 2010 dependent children covered to age 26 for medical and prescription plans due to the passing of the Health Care Reform Act of March 30, 2010. APPENDIX E HEALTH BENEFIT PLAN SUMMARIES MATRIX CIGNA HDHP-HSA BENEFIT High Deductible Health Plan/ Costshares Health Savings Account Deductible - $2,000/$4,000 Coinsurance - 100% after plan deductible met for in network services $4,000/$8,000 out of pocket maximum Coinsurance - 80% Co-Insurance in network 60% after plan deductible met for out of network services Employer Contribution $1,000 single coverage $2,000 double or family coverage Lifetime Maximum In-Network - Unlimited Lifetime Maximum Out-Of-Network - Unlimited Preventive Care Pediatric Covered Adult Covered Hearing Covered Screening part of physical exam Gynecological Covered Medical Services Medical Office Visit Covered 100% after plan deductible met Outpatient PT/OT/ST/Chiro. Covered 100% after plan deductible met 60 Combined Days per calendar year per member Allergy Services Covered 100% after plan deductible met Diagnostic Lab & X-ray Covered 100% after plan deductible met Inpatient Medical Services Covered 100% after plan deductible met Surgery Fees Covered 100% after plan deductible met Office Surgery Covered 100% after plan deductible met APPENDIX E HEALTH BENEFIT PLAN SUMMARIES (CONTINUED) MATRIX CIGNA HDHP-HSA BENEFIT High Deductible Health Plan/ Outpatient MH/SA Covered 100% after plan deductible met Emergency Care Emergency Room Covered 100% after plan deductible met Urgent Care $75 Copay $50 Copay $75 Copay After Deductible 80% Co-Insurance in network 60% out of network Walk-In Centers $15 Copay $15 Copay $20 Copay After Deductible 80% Co-Insurance in network 60% out of network Ambulance Unlimited for Land and Air Unlimited for Land and Air 20Covered 100% after plan deductible in or out of network After Deductible 80met Ambulance Covered 100% Co-Insurance in network 60% out of network INPATIENT HOSPITAL- Inpatient- after plan deductible met Inpatient Hospital Health Savings Account General/Medical/Surgical/ Maternity (Semi-Privateprivate) All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admissions Require Pre-Cert $250 Per Admission Copay All Hospital Admission Require Pre-Cert 20Covered 100% after plan deductible met Ancillary Services Medication, Supplies Covered 100% after plan deductible met Psychiatric Covered 100% after plan deductible met Unlimited days Substance Abuse/Detox Covered 100% after plan deductible met Unlimited days Skilled Nursing/Rehabilitation Facility Covered 100% after plan deductible met Covered up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Ancillary Services- Medications and Supplies 180 days per calendar year Hospice Covered Covered 20100% after plan deductible up to the out of pocket maximum All met Outpatient Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Mental Health $250 Copay Per Admission Copay $250 Per Admission Copay 20Outpatient Surgery Facility Charges Covered 100% after plan deductible up to the out of pocket maximum All Hospital Admissions Require Premet (Prior Authorization Required) Diagnostic Lab & X-Cert After Deductable 80% in Network 60% Out of Network (Biologically Based) Unlimited Days Unlimited Days Unlimited Days Mental Health $250 Copay Per Admission Copay $250 Copay Per Admission Copay 20ray Covered 100% after plan deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network (Non-Biologically Based) Unlimited Days Unlimited Days Unlimited Days Unlimited Days Substance Abuse $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network Unlimited Days Unlimited Days Unlimited Days Unlimited Days Rehabilitative Services $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 60 Days Per Calendar Year 60 Days Per Calendar Year 60 Days Per Calendar Year 100 Days Per Calendar Year Skilled Nursing Facility $250 Per Admission Copay $250 Per Admission Copay 20% after deductible up to the out of pocket maximum All Hospital Admissions Require Pre-Cert After Deductable 80% in Network 60% Out of Network 120 Days Per calendar Year 120 Days Per calendar Year 120 Days Per calendar Year 100 Days Per calendar Year Outpatient Surgery Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required (Facility Charges) $200 Copay $200 Copay 20% after deductible up to the out of pocket maximum After Deductible 80% Co-Insurance in network 60% out of network Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) $100 Ambulatory surgery (in a hospital setting) After Deductible 80% / 60% met Pre-Admission Testing Covered 100% after plan deductible met Other Services Durable Medical Equipment Covered After 100% after plan deductible met Prosthetics Covered 100% after plan deductible met Home Health Care Covered 100% after plan deductible met Unlimited days APPENDIX E HEALTH BENEFIT PLAN SUMMARIES (CONTINUED) MATRIX CIGNA HDHP-HSA BENEFIT High Deductible 80% Co- Insurance in network 60% out of network After Deductible 80% Co-Insurance in network 60% out of network Diagnostic Lab & X-Ray Covered Covered Covered Health Plan/ (Prior Authorization Required High Cost Diagnostic Required) Vision Covered 100% after plan deductible met Covered once every 24 months Prescriptions prior to 7/1/2016 (MRICoverage through Cigna) Covered 100% after plan deductible met Three Tier Formulary RX Rider Prescriptions (Coverage through Cigna) Rx copays apply after the deductible is met $5/$20/$35 Three Tier Formulary RX Rider * All benefits listed are for In-Network. For Out-of-Network benefits, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) High Cost Diagnostic (MRI, MRA, CAT, CTA, PET, Spect) requires prior auth and a $75 copay per service up please refer to your Employee Benefit Summary. ** Plan is Non-Gatekeeper. No referrals are required. No primary care physician is required. INFERTILITY: Coverage is subject to a $375 requires prior auth and a $75 copay per service up to a $375 requires prior auth and a $75 copay per service up to a $375 After Deductible 80% Co-Insurance in network 60% out of network calendar year maximum calendar year maximum calendar year 5,000 lifetime maximum