IN-NETWORK MEMBER PAYS OUT-OF-NETWORK MEMBER PAYS. Calendar Year Plan Deductible. services and prescription drugs) Out-of-Pocket Maximum

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POS HDHP $3,000/$6,000 Deductible-F Point-of-Service Open Access High Deductible Health Plan for use with a Health Savings Account (HSA) Benefit Summary This is a brief summary of benefits.

1 POS HDHP $3,000/$6,000 Deductible-F Point-of-Service Open Access High Deductible Health Plan for use with a Health Savings Account (HSA) Benefit Summary This is a brief summary of benefits. Refer to your ConnectiCare Insurance Company, Inc. policy for more information. The policy will prevail for all benefits, conditions, limitations and exclusions. It is important that you read your policy. All benefits described below are per member per Calendar year. A referral from your primary care physician is not required. The individual deductible applies if you have coverage only for yourself and not for any dependents. The family deductible applies if you have coverage for yourself and one or more eligible dependents. In addition, if you have family coverage, any applicable copayment, coinsurance or cost share maximums will apply until the total is met for the family, without regard to how much any one family member has met. Calendar Year Plan Deductible (Deductible is combined for health services and prescription drugs) Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services) Out-of-Network Reimbursement Lifetime Maximum Benefit PREVENTIVE SERVICES (Refer to "Prevention and Wellness" section found at the end of this summary) Adult Physical Exam (one exam per Calendar year when provided by a PCP) Infant / Pediatric Physical Exam (frequency limits apply and exam must be provided by a PCP) Gynecological Preventive Exam Preventive Laboratory Services (Complete blood count and urinalysis, one test per year) Baseline Routine Mammography (ages 35-39) $3,000 Individual $6,000 Family $3,000 Individual $6,000 Family Not Applicable Unlimited $6,000 Individual $12,000 Family $10,000 Individual $20,000 Family Plan will reimburse the coinsurance percentage of the Maximum Allowable Amount. Unlimited 1

2 PREVENTIVE SERVICES (Refer to "Prevention and Wellness" section found at the end of this summary) Annual Routine Mammography (age 40 or older) Breast Ultrasound Screening Annual Routine Vision Exam (one exam per year when provided by an Optometrist or Ophthalmologist) OUTPATIENT SERVICES Primary Care Provider Office Services (includes services for illness, injury, sickness, follow-up care and consultations) Specialist Office Services (includes services for illness, injury, sickness, follow-up care and consultations) Maternity Care Office Visits Allergy Testing one visit per year Allergy Injections up to 20 visits per year Laboratory Services (includes services performed in a Hospital or laboratory facility) Non-Advanced Radiology (includes services performed in a Hospital or radiology facility) Advanced Radiology (includes services for MRI, PET and CAT Scan, and nuclear cardiology performed in a Hospital or radiology facility) Outpatient Rehabilitative and Habilitative Therapy up to 40 visits per year (includes services combined for physical, speech, and occupational therapy) Chiropractic Services up to 20 visits per year Retail Clinic No Member cost (Plan Deductible waived) No Member cost 2

3 EMERGENCY / URGENT CARE Walk-In/Urgent Care Centers Emergency Room (Copayment waived if admitted) Ambulance Services HOSPITAL SERVICES Inpatient Hospital Services, Including Room & Board Same as In-Network Same as In-Network Same as In-Network Hospital Outpatient Surgical Facilities (includes services performed in a Hospital facility) Ambulatory Surgical Center (includes services performed in a stand-alone ambulatory facility) Skilled Nursing and Rehabilitation Facilities up to 90 days per year MENTAL HEALTH SERVICES Inpatient Mental Health Services (including inpatient acute and residential programs) Inpatient Alcohol and Substance Abuse Treatment (including inpatient acute and residential programs) Outpatient Mental Health, Alcohol and Substance Abuse Treatment (including office visits and professional services provided in the home) Outpatient Mental Health, Alcohol and Substance Abuse Treatment (intensive outpatient treatment and partial hospitalization programs) OTHER SERVICES Disposable Medical Supplies, Durable Medical Equipment and Ostomy Supplies and Equipment Diabetic Equipment and Supplies 3

4 OTHER SERVICES Home Health Services up to 100 visits per year 25% after Plan Deductible Pediatric-Only Services (for children under age 19) Pediatric Dental Care Diagnostic & Preventive Basic Restorative Major Restorative Orthodontia Services (medically necessary only) Pediatric Vision Care Routine Eye Exam (one exam per year) Prescription Eye Glasses (one pair of frames and lenses per year) No Member cost No Member cost Lenses: $0 after Plan Deductible Collection frames: $0 after Plan Deductible Non-collection frames: $0 after Plan Deductible up to the collection frame allowance; any amount over is payable by the member minus a 20% discount 4

5 PREVENTION AND WELLNESS 1 In-Network prevention and wellness services as defined by the United States Preventive Service Task Force (listed below) are exempt from all member cost share (deductible, copayment and coinsurance) under the Patient Protection and Affordable Care Act (PPACA). Services that are exempt from cost share must be identified by the specific codes. The codes your health care provider submits must match ConnectiCare s coding list to be exempt from all cost share. 1 Routine physical exam and appropriate screening and counseling for adults (including but not limited to depression, obesity and sexually transmitted infections), one per year 1 Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administrationn (including but not limited to depression, obesity and sexually transmitted infections) 1 Preventive care and screenings for women supported by the Health Resources and Services Administration: 4 At least one well-woman preventive care visit annually to obtain the recommended preventive services 4 Screening for diabetes during pregnancy, two per pregnancy 4 Human Papillomavirus (HPV) testing, age 30 or older, one per year 4 Counseling on sexually transmitted infections for all sexually active women, two per year 4 Counseling and screening for human immune-deficiency virus (HIV) for all sexually active women 4 Contraceptive methods approved by the Food and Drug administration, sterilization procedures and contraceptive patient education and counseling 4 Comprehensive lactation support, counseling, a manual breast pump, and breastfeeding supplies 4 Screening and counseling for interpersonal and domestic violence for all women and adolescents 1 Bone density screenings, age 60 or older, one every 23 months 1 Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, age 50 or older, one per year 1 Routine mammography screening, age 40 or older, one per year 1 Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC 1 Outpatient laboratory services, one per year: 4 Cervical cancer and cervical dysplasia screening pap smear 4 Lipid cholesterol screening for adults and children at risk 4 Fasting plasma glucose or hemoglobin A1c, age 18 and older for people at risk for diabetes 4 Hematocrit and Hemoglobin, for children up to age Lead screening, for children up to age 6 4 Tuberculin testing, for children up to age 21 4 Chlamydia, syphilis and gonorrhea screening for females all ages 4 Human immunodeficiency virus screening HIV testing (no limit) 4 Hypothyroidism screening in newborns, under 3 months of age 4 Screening for phenylketonuria (PKU) in newborns, under 3 months of age 4 Screening for sickle cell disease in newborns, under 3 months of age 4 Hepatitis B screening for adolescents and adults at risk 4 Hepatitis C screening for adults ages at risk 4 Lung Cancer screening for adults ages who have smoked 1 Routine vision screening up to age 21, one per year when services are rendered by a primary care provider 1 Routine hearing screening up to age 21 when rendered by a primary care provider 1 Dental caries prevention up to age 5 when rendered by a primary care provider 1 Developmental, autism, and psychosocial/behavioral assessments when rendered by a primary care provider. 1 Dietary counseling for adults with hyperlipidemia or obesity 1 Alcohol misuse screening and counseling 1 Tobacco cessation interventions 1 Screening for hepatitis B, iron deficient anemia, Rh (D) blood typing and asymptomatic bacteriuria in women who are pregnant. 1 Screening for abdominal aortic aneurysm in men age who have ever smoked 1 BRCA counseling and genetic screening for women at risk 1 Physical therapy to prevent falls in adults ages 65 and older Go to for more information on preventive care. 5

6 Important Information 1 If you have questions regarding your plan, visit our website at or call us at (860) or Many services require that you obtain our pre-certification or pre-authorization prior to obtaining care prescribed or rendered by network provider or non-participating providers. A reduction will apply if you do not obtain pre-authorization for these specified services. For mental health, alcohol, and substance abuse services call to obtain pre-authorization. 1 Out-of-Network reimbursement is based on the maximum allowable amount. Members are responsible to pay any charges in excess of this amount. Please refer to your ConnectiCare Insurance Company, Inc. policy for more information. 1 This plan is insured by ConnectiCare Insurance Company, Inc. Benefits are Pending Department of Insurance Approval 6

7 Prescription Drug Copayment Plan Benefit Summary This is a brief summary of benefits. Refer to your ConnectiCare Insurance Company, Inc. policy for more information. The policy will prevail for all benefits, conditions, limitations and exclusions. It is important that you read your policy. All benefits described below are per member per Calendar year. A referral from your primary care physician is not required. The individual deductible applies if you have coverage only for yourself and not for any dependents. The family deductible applies if you have coverage for yourself and one or more eligible dependents. In addition, if you have family coverage, any applicable copayment, coinsurance or cost share maximums will apply until the total is met for the family, without regard to how much any one family member has met. PRESCRIPTION DRUGS Covered prescription drugs through retail Participating Pharmacies or our mail order service. Generics are dispensed unless the Member pays the Generic Cost-Share plus the difference in price between the Generic Equivalent and the Brand Name Drug. Your Plan includes the following: Mandatory Drug Substitution, Generic Substitution Program, Tiered Cost-Share Program, and Voluntary Mail Order Program. Calendar Year Plan Deductible Out-of-Pocket Maximum (Includes a combination of deductible, copayment and coinsurance for health and pharmacy services) Out-of-Network Reimbursement RETAIL PHARMACY (up to a 30 day supply per prescription) Tier 1 drugs Tier 2 drugs Tier 3 drugs $3,000 Individual $6,000 Family The Calendar Year Deductible can be reached by any combination of covered Health Services or covered prescription drug services. If you have Family coverage, then covered Health Services and covered prescription drugs will be applied to the Family Plan Deductible until the total amount is met without regard to which family member uses the benefits. $3,000 Individual $6,000 Family Not applicable $6,000 Individual $12,000 Family The Calendar Year Deductible can be reached by any combination of covered Health Services or covered prescription drug services. If you have Family coverage, then covered Health Services and covered prescription drugs will be applied to the Family Plan Deductible until the total amount is met without regard to which family member uses the benefits. $10,000 Individual $20,000 Family Plan will reimburse the coinsurance percentage of the Maximum Allowable Amount. 7

8 RETAIL PHARMACY (up to a 30 day supply per prescription) Tier 4 drugs MAIL ORDER PHARMACY (up to a 90 day supply per prescription) Tier 1 drugs Tier 2 drugs Tier 3 drugs Tier 4 drugs Additional Information 100% 100% 100% 100% 1 Under this program covered prescription drugs and supplies are put into categories (i.e., tiers) to designate how they are to be covered and the member's cost-share. The placement of a drug or supply into one of the tiers is determined by the ConnectiCare Pharmacy Services Department and approved by the ConnectiCare Pharmacy & Therapeutics Committee based on the drug's or supply's clinical effectiveness and cost, not on whether it is a generic drug or supply or brand name drug or supply. 1 Generic drugs can reduce your out-of-pocket prescription costs. Generics have the same active ingredients as brand name drugs, but usually cost much less. So, ask your doctor or pharmacist if a generic alternative is available for your prescription. Also, remember to use a participating pharmacy. Most pharmacies in the United States participate in our network. To find one, visit our Web site at or call our Member Services Department at Certain prescription drugs and supplies require pre-authorization from us before they will be covered under the prescription drug rider. You should visit our Web site at or call our Member Service Department at to find out if a prescription drug or supply requires pre-authorization. 1 Always remember to carry your ConnectiCare ID Card. 1 If you are a Massachusetts resident, please refer to your amendatory rider for Massachusetts mandated benefits for additional details of your benefits. Benefits are Pending Department of Insurance Approval 8

OUT-OF-NETWORK MEMBER PAYS IN-NETWORK MEMBER PAYS. Contract Year Plan Deductibles. services and prescription drugs) Out-of-Pocket Maximum

OUT-OF-NETWORK MEMBER PAYS IN-NETWORK MEMBER PAYS. Contract Year Plan Deductibles. services and prescription drugs) Out-of-Pocket Maximum FlexPOS-CNT-HSA-6000I/12000F-01 Open Access Contract Year Benefit Summary (E) Point-Of-Service Open Access High Deductible Health Plan (HDHP) for use with a Health Savings Account (HSA) This is a brief