$4,800 $9,600 Maximum Lifetime Benefit

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1 PPO Schedule of PPO Medical C & A Industries, Inc. Plan Effective Date: January 1, 2019 In-Network Out-of-Network** Benefit Year means a calendar year, which is the period of twelve (12) consecutive months commencing on January 1 st, and continuing through December 31 st of that year. Deductible (Per Benefit Year) Individual Deductible Family Deductible $1,000 $2,000 $2,000 $4,000 10% 30% Out-of-Pocket Maximum (Per Benefit Year) The Out-of-Pocket Maximum includes Deductible and. Individual Deductible Family Deductible $2,400 $4,800 $4,800 $9,600 Maximum Lifetime Benefit Unlimited (while covered under the Plan) NOTE: In-Network and Out-of-Network Deductible and Out-of-Pocket Maximum are combined. Visit limits and Maximum are combined for both In-Network and Out-of-Network. Covered Services Preventive Services For services billed as routine including physicals, laboratory, well-baby care, well-child care, well-woman care, mammograms, prostate cancer screening, colon cancer screening, diabetes screening, certain osteoporosis screenings, behavioral health screening, flu shots, and adult and childhood immunizations Routine Mammograms Routine Scopic Examinations Physician Office Services Physician Office Visit * For non-preventative Services billed by a Physician s office including: Non-routine laboratory and radiology services Allergy Testing Convenient Care Clinic 0% 0% 0% $30 Copayment Specialist Physician Office Visit For non-preventive Services billed by a Physician s office including: Non-routine laboratory and radiology services Allergy Testing Telemedicine In-Network virtual care Physician Visits Access to a physician via mobile phone, tablet or computer $40 Copayment $25 Copayment 20% N/A

2 Clinic/Office Based Surgical Services Covered Services Allergy Injections Maternity Services Maternity services includes prenatal, delivery, and postnatal Physician services and office visits. For Hospital charges related to delivery or other Inpatient Hospital care, refer to for Inpatient Hospital. Urgent Care Facility Outpatient Facility For non-preventative Services including: Services performed at a Hospital or free-standing facility Professional services Non-routine laboratory, radiology and diagnostic testing services Emergency Services Hospital Emergency Room Ambulance Inpatient Hospital Services Inpatient Hospital care, including semi-private room & board, intensive / coronary care, maternity care, x-ray, laboratory, professional services and other facility and ancillary charges Inpatient Rehabilitation facility services (limited to 60 days per Benefit Year) Short Term Therapies Speech Therapy Coverage for up to 30 visits per Benefit Year Occupational Therapy/Physical Therapy Coverage for up to 60 visits per Benefit Year combined Cardiac/Pulmonary Rehabilitation Manipulative Therapies Spinal Manipulation Coverage for up to 30 visits per Benefit Year Other Services Family Planning Elective sterilization, female $30 Copayment then 0% 40% Same benefit as In- Network Same benefit as In- Network 40% Elective sterilization, male Infertility diagnosis only No coverage

3 Covered Services Infertility treatment Craniofacial Disorder Benefit High End Radiology (MRIs, PET Scans, CT Scan, etc.) Independent Radiology and Pathology Center Surgical Services (Inpatient & Outpatient) Non Surgical Services (Inpatient & Outpatient) Skilled Nursing Facility (Up to 100 days per Benefit Year) Home Health Care (Up to 100 visits per Benefit Year) Hospice Care Inpatient & Outpatient No coverage Counseling Services Bereavement Services Durable Medical Equipment (DME) Prosthetic Devices Transplant Services Donor services are only covered when the recipient is a Covered Person. If performed at a UHC Transplant Network facility approved by the Plan, donor services are covered at 100% If not performed at a UHC Transplant Network facility approved by the Plan, services are not covered. Specialty Drugs and Medicines (other than those purchased through a Specialty Pharmacy provider) 0% 0% 0% 0%

4 Covered Services Mental Disorder, Substance-Related Disorder Services, and/or Biologically Based Mental Illness Coverage (with the exception of certain screenings) Office services All other services $40 Copayment Prescription Drug Mandatory Generic Substitution: If a Brand Name Prescription is dispensed and an equivalent Tier One Generic is available, the member shall pay an Ancillary Charge (the price difference between the Brand and Generic drug) directly to the pharmacy in addition to the Brand Name copayment. The Ancillary Charge does not go towards member s Out-of-Pocket costs. Specialty Drugs are high-cost prescription medications used to treat complex, chronic conditions like cancer, rheumatoid arthritis and multiple sclerosis. Patients using a specialty drug often must be monitored closely to determine if the therapy is working and to watch for side effects. Specialty Rx has a 20% co-insurance with a maximum out-of-pocket of $200 per fill. Retail (30-day Supply) Tier One Formulary $10 50% Tier Two Formulary $30 50% Tier Three Formulary $50 50% Mail Order (90 day Supply Tier One Formulary $20 N/A Tier Two Formulary $60 N/A Tier Three Formulary $100 N/A *Primary Care Physicians ( PCP ) generally include the Physicians who practice in the specialties of Family Practice, Internal Medicine, General Practice, OB/GYN or Pediatrics. If You are not sure if a Physician is a PCP, please contact the Customer Service Number on the back of Your ID card. If You receive a service from a PCP, Your PCP member responsibility will apply. If You receive this service from a Specialist, Your Specialist benefit will apply. **When receiving services from Non-Participating Providers, payment for covered services is limited to the lesser of the billed charge, or the Out-of-Network allowable amount, less applicable Copayment, and/or Deductibles. Please refer to the Summary Plan Description for additional details. Only services and treatments that meet bother the Medical Necessity criteria and are listed as a covered service in the Plan will be covered. Services and treatments listed under the Plan Exclusions Section are not covered, regardless of Medical Necessity. Even though Your provider may recommend a procedure, service, or supply, the care may not always be Medically Necessary. See Your Summary Plan Description (SPD) for further details on Medical Necessity, covered services and a listing of Plan Exclusions.

5 Some Covered Services that You receive during a Preventative Services visit may not qualify as Preventative Services under the Plan and consequently, will be subject to applicable Copayment, and/or Deductible. It is Your obligation to ensure that any required Prior Authorization has been obtained. Failure to do so may result in a financial penalty of 50% up to $1,000 or reduction in benefits in You do not Prior Authorize a planned hospitalization or elective surgery. Before You receive services, supplies, or procedures, You or Your Participating Physician must request any necessary Prior Authorization. If You choose to have requested services performed even though the Plan was unable to certify the Medical Necessity of the services, You will be responsible for the charges. If You are unsure if a service requires Prior Authorization, contact the Plan at the Customer Service phone number listed on the back of Your ID card prior to receiving care. This Schedule is part of Your Summary Plan Description (SPD) but does not replace it. Many words are defined elsewhere in the SPD and other limitations or Plan Exclusions may be listed in other sections of Your SPD. Reading this Schedule by itself could give You an inaccurate impression of the terms of Your coverage. This Schedule must be read with the rest of Your SPD. A complete list of covered Services, Plan Exclusions, and limitations can be found in Your SPD.