2018 Health Coverage Comparison Chart

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1 Invested in weighing the possibilities 08 Health Coverage Comparison Chart Making the right choice is important. Here s some information you ll need to help make more informed decisions. What s Inside The information on the following pages provides highlights and contributions* for all of the health care options available to you for 08. *These contribution amounts do not reflect any premium reduction associated with Fidelity s Health Improvement & Incentive Program.

2 Medical Coverage Comparison Chart KEY PROVISIONS ANNUAL DEDUCTIBLE ANNUAL OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE) FIDELITY HEALTH PLAN $,500 for Individual coverage. $3,000 if you cover yourself and one or more family members. 5 $,000 for Individual coverage. $4,000 if you cover yourself and one or more family members. 5 HEALTHFLEX PPO $300 6 per person up to the family 5 maximum of $ $,500 per person up to the family 5 maximum of $3,000. HEALTH MAINTENANCE ORGANIZATIONS (HMOs) VARY BY STATE 3, 4 None. $,000 per person up to the family 5 maximum of $4,000. REFERRALS Not required. Not required. Varies by plan. Contact your HMO for details as to whether referrals are required. OFFICE VISITS Routine Well Office Visits and Screenings Covered at 00%, no copay. Covered at 00%, no copay. Covered at 00%, no copay. Well Baby/Well Child Visits Covered at 00%, no copay. Covered at 00%, no copay. Covered at 00%, no copay. Diagnostic Visits Covered at 90%, after deductible. Covered at 00%, after $0 copay. Covered at 00%, after $0 copay. Specialty Visits Covered at 90%, after deductible. Covered at 00%, after $40 copay. Covered at 00%, after $40 copay. MATERNITY CARE Prenatal Care Covered at 00%, no copay. Covered at 00%, no copay. Covered at 00%, no copay. Hospital & Delivery Services Covered at 90%, after deductible. Covered at 90%, after deductible. Covered at 00%, after $300 copay. Postnatal Exams Covered at 90%, after deductible. Covered at 00%, no copay. Covered at 00%, no copay. HOSPITAL CARE Inpatient Care Covered at 90%, after deductible. Covered at 90%, after deductible. Covered at 00%, after $300 copay. Emergency Room Covered at 90%, after deductible. Covered at 00%, after $50 copay (waived if admitted). Outpatient Surgery Covered at 90%, after deductible. In facility: Covered at 90%, after deductible. In physician s office: Covered at 00%, after $40 copay. OUTPATIENT (PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY) MENTAL HEALTH/ SUBSTANCE ABUSE Inpatient Outpatient CHIROPRACTIC AND ACUPUNCTURE SERVICES VISION AND HEARING EXAMS Covered at 90%, after deductible. Physical and occupational therapy limited to 60 visits per year combined. Speech therapy limited to 5 visits per year. unlimited days per calendar year. unlimited visits per calendar year. limited to 0 visits per year for chiropractic and acupuncture services (not combined). Covered at 00%, no copay (one vision exam and one hearing exam per year). Covered at 00%, after $40 copay per visit. Physical and occupational therapy limited to 60 visits per year combined. Speech therapy limited to 5 visits per year. unlimited days per calendar year. Covered at 00%, after $0 copay per visit; unlimited visits per calendar year. limited to 0 visits per year for chiropractic and acupuncture services (not combined). Covered at 00%, no copay (one vision exam and one hearing exam per year). Covered at 00%, after $50 copay (waived if admitted). In facility: Covered at 00%, no copay. In physician s office: Covered at 00%, after $40 copay. Covered at 00%, after $40 copay per visit. Physical and occupational therapy limited to 60 visits per year combined. Speech therapy limited to 5 visits per year. Covered at 00%, after $300 copay; unlimited days per calendar year. Covered at 00%, after $0 copay per visit; unlimited visits per calendar year. Covered at 00%, after $40 copay per visit. Limited to 0 visits per year for chiropractic and acupuncture services (not combined). Covered at 00%, no copay (one vision exam and one hearing exam per year). Prior authorization for services may be required. Please contact the carrier for more information. Coverage information pertains only to in-network providers; coverage for out-of-network providers is reduced. For purposes of this chart, HMO means an HMO-like self-funded plan. 3 You must reside in the appropriate service area in the states offered to obtain the HMO coverage. 4 There may be slight variations by state. Please check your Summary Plan Description or contact the plan carrier for detailed coverage information. 5 If you want to cover family members, you ll need to choose one of the following tiers: Individual + Child(ren), Individual + Spouse, or Individual + Family. 6 Copay amounts do not apply to the annual deductible.

3 Medical Coverage Comparison Chart (Continued) KEY PROVISIONS FIDELITY HEALTH PLAN HEALTHFLEX PPO HEALTH MAINTENANCE ORGANIZATIONS (HMOs) VARY BY STATE 3, 4 PRESCRIPTION COVERAGE Administered by CVS Caremark Retail (30-day supply) Generic/ Preferred/Non-Preferred Preventive: Covered at 00%, after applicable copay ($0/$0/$40). 5 Non-preventive: Covered at 90%, after deductible. Covered at 00%, after applicable copay ($0/$0/$40). Covered at 00%, after applicable copay ($0/$0/$40). Mail Order (90-day supply) Generic/Preferred/Non-Preferred Preventive: Covered at 00%, after applicable copay ($0/$40/$80). 5 Non-preventive: Covered at 90%, after deductible. Covered at 00%, after applicable copay ($0/$40/$80). Covered at 00%, after applicable copay ($0/$40/$80). Prior authorization for services may be required. Please contact the carrier for more information. Coverage information pertains only to in-network providers; coverage for out-of-network providers is reduced. For purposes of this chart, HMO means an HMO-like self-funded plan. 3 You must reside in the appropriate service area in the states offered to obtain the HMO coverage. 4 There may be slight variations by state. Please check your Summary Plan Description or contact the plan carrier for detailed coverage information. 5 Preventive prescription drug copays will not apply toward the deductible, but will apply toward the out-of-pocket maximum. Changes have been made to the preventive drug list, so please be sure to check if your current drug is still covered under preventive. BIWEEKLY MEDICAL CONTRIBUTIONS + EMPLOYEES WITH BASE SALARY OR BENEFITS BASE OF LESS THAN $50,000 AS OF 8//07 FIDELITY HEALTH PLAN $43.00 $30.00 $76.00 $33.00 $0.00 $ $44.00 $43.00 HEALTHFLEX PPO $65.00 $53.00 $4.00 $76.00 $44.00 $ $05.00 $ AETNA MID-ATLANTIC HMO (CT, NJ, NY, PA) $83.00 $73.00 $49.00 $33.00 $9.00 $ $73.00 $ AETNA TEXAS HMO (TX) $83.00 $73.00 $49.00 $33.00 $9.00 $ $73.00 $ CIGNA HMO (NC) $80.00 $64.00 $40.00 $94.00 $66.00 $35.00 $44.00 $50.00 HARVARD PILGRIM HMO (ME, MA, NH, RI) $78.00 $67.00 $40.00 $30.00 $7.00 $ $45.00 $ HUMANA HMO (IN, KY, OH) $7.00 $6.00 $7.00 $90.00 $6.00 $ $3.00 $57.00 SELECTHEALTH HMO (UT) $7.00 $63.00 $3.00 $94.00 $57.00 $ $30.00 $50.00 EMPLOYEES WITH BASE SALARY OR BENEFITS BASE BETWEEN $50,000 AND $74,999 AS OF 8//07 FIDELITY HEALTH PLAN $48.00 $30.00 $84.00 $33.00 $3.00 $ $60.00 $43.00 HEALTHFLEX PPO $7.00 $53.00 $4.00 $76.00 $57.00 $ $4.00 $ AETNA MID-ATLANTIC HMO (CT, NJ, NY, PA) $89.00 $73.00 $59.00 $33.00 $04.00 $ $9.00 $ AETNA TEXAS HMO (TX) $89.00 $73.00 $59.00 $33.00 $04.00 $ $9.00 $ CIGNA HMO (NC) $86.00 $64.00 $50.00 $94.00 $79.00 $35.00 $63.00 $50.00 HARVARD PILGRIM HMO (ME, MA, NH, RI) $84.00 $67.00 $50.00 $30.00 $85.00 $ $64.00 $ HUMANA HMO (IN, KY, OH) $78.00 $6.00 $37.00 $90.00 $76.00 $ $5.00 $57.00 SELECTHEALTH HMO (UT) $78.00 $63.00 $4.00 $94.00 $7.00 $ $49.00 $50.00 EMPLOYEES WITH BASE SALARY OR BENEFITS BASE BETWEEN $75,000 AND $49,999 AS OF 8//07 FIDELITY HEALTH PLAN $5.00 $30.00 $90.00 $33.00 $.00 $ $7.00 $43.00 HEALTHFLEX PPO $88.00 $53.00 $58.00 $76.00 $97.00 $ $84.00 $ AETNA MID-ATLANTIC HMO (CT, NJ, NY, PA) $08.00 $73.00 $96.00 $33.00 $50.00 $ $ $ AETNA TEXAS HMO (TX) $08.00 $73.00 $96.00 $33.00 $50.00 $ $ $ CIGNA HMO (NC) $05.00 $64.00 $84.00 $94.00 $.00 $35.00 $34.00 $50.00 HARVARD PILGRIM HMO (ME, MA, NH, RI) $03.00 $67.00 $86.00 $30.00 $9.00 $ $37.00 $ HUMANA HMO (IN, KY, OH) $96.00 $6.00 $7.00 $90.00 $8.00 $ $34.00 $57.00 SELECTHEALTH HMO (UT) $98.00 $63.00 $76.00 $94.00 $.00 $ $3.00 $50.00

4 BIWEEKLY MEDICAL CONTRIBUTIONS + EMPLOYEES WITH BASE SALARY OR BENEFITS BASE BETWEEN $50,000 AND $49,999 AS OF 8//07 FIDELITY HEALTH PLAN $59.00 $30.00 $04.00 $33.00 $39.00 $ $96.00 $43.00 HEALTHFLEX PPO $06.00 $53.00 $90.00 $76.00 $40.00 $ $34.00 $ AETNA MID-ATLANTIC HMO (CT, NJ, NY, PA) $7.00 $73.00 $3.00 $33.00 $90.00 $ $40.00 $ AETNA TEXAS HMO (TX) $7.00 $73.00 $3.00 $33.00 $90.00 $ $40.00 $ CIGNA HMO (NC) $.00 $64.00 $8.00 $94.00 $6.00 $35.00 $ $50.00 HARVARD PILGRIM HMO (ME, MA, NH, RI) $0.00 $67.00 $9.00 $30.00 $69.00 $ $ $ HUMANA HMO (IN, KY, OH) $3.00 $6.00 $04.00 $90.00 $60.00 $ $ $57.00 SELECTHEALTH HMO (UT) $6.00 $63.00 $.00 $94.00 $5.00 $ $ $50.00 EMPLOYEES WITH BASE SALARY OR BENEFITS BASE OF $50,000 OR MORE AS OF 8//07 FIDELITY HEALTH PLAN $65.00 $30.00 $3.00 $33.00 $5.00 $ $4.00 $43.00 HEALTHFLEX PPO $.00 $53.00 $00.00 $76.00 $5.00 $ $36.00 $ AETNA MID-ATLANTIC HMO (CT, NJ, NY, PA) $34.00 $73.00 $44.00 $33.00 $ $ $44.00 $ AETNA TEXAS HMO (TX) $34.00 $73.00 $44.00 $33.00 $ $ $44.00 $ CIGNA HMO (NC) $8.00 $64.00 $3.00 $94.00 $78.00 $35.00 $ $50.00 HARVARD PILGRIM HMO (ME, MA, NH, RI) $7.00 $67.00 $3.00 $30.00 $85.00 $ $40.00 $ HUMANA HMO (IN, KY, OH) $0.00 $6.00 $6.00 $90.00 $75.00 $ $ $57.00 SELECTHEALTH HMO (UT) $.00 $63.00 $.00 $94.00 $65.00 $ $39.00 $50.00 Dental Coverage Information KEY PROVISIONS COVERAGE SERVICES INCLUDED IN TREATMENT ANNUAL DEDUCTIBLE BENEFIT MAXIMUM $50 per covered person, 3 $50 per family maximum (each family member can only apply $50 toward the family deductible). Dental Services: $,000 per covered person per calendar year Orthodontic Services: $,500 per covered person per lifetime. PREVENTIVE TREATMENT Covered at 00%. 4 Oral exams, routine cleanings, X-rays, sealants, fluoride treatments, and space maintainers. BASIC TREATMENT MAJOR RESTORATIVE AND ORTHODONTIC TREATMENT Covered at 80% 4 after deductible. Covered at 60% 4 after deductible. Fillings, oral surgery, periodontal treatment, endodontics, extractions, and diagnostic lab tests. Crowns and bridgework, dentures, implants, inlays, and onlays. Orthodontic treatment subject to lifetime maximum. This is a sample list of services covered under each treatment; see the Summary Plan Description for a list of all services covered. Deductible applies to basic and major restorative treatment only (excludes orthodontic treatment). 3 If you want to cover family members, you ll need to choose one of the following tiers: Individual + Child(ren), Individual + Spouse, or Individual + Family. 4 Coverage is either the cost provided by a preferred dental provider or the Reasonable and Customary (R&C) amount. BIWEEKLY DENTAL CONTRIBUTIONS + $8.00 $7.00 $6.00 $3.00 $0.00 $38.00 $9.00 $56.00

5 Vision Coverage Information KEY PROVISIONS IN NETWORK OUT-OF-NETWORK EXAM Covered at 00%, no copay. Up to $50 reimbursement. EYEGLASSES Frames Covered at 00% up to $50 allowance. Up to $75 reimbursement. Lenses (single, bifocal, trifocal) CONTACT LENSES (in lieu of eyeglasses) Covered at 00% after $0 copay. Covered at 00% up to $50 allowance. Up to $50 reimbursement. Up to $75 reimbursement. ADDITIONAL DISCOUNTS 0% discount on frame balance above $50. FREQUENCY OF SERVICES Exam Frames and lenses OR contact lenses 40% discount on additional pairs of eyeglasses. 0% discount on non-prescription sunglasses. Discounts on LASIK and PRK. Once every calendar year. Once every calendar year. Not available out of network. If you want to cover family members, you ll need to choose one of the following tiers: Individual + Child(ren), Individual + Spouse, or Individual + Family. This is a sample list of services; refer to FMRbenefits.com for a list of all services covered. BIWEEKLY VISION CONTRIBUTIONS + $.00 $.00 $.00 $4.00 $.00 $4.00 $3.00 $6.00 Health Care Biweekly Contributions EMPLOYEE COSTS MEDICAL DENTAL VISION Costs for each medical plan option are based on your salary and your work status full-time (regular employees regularly scheduled to work 30 or more hours per week) or part-time (regular employees regularly scheduled to work at least 0 but less than 30 hours per week). Costs for the dental plan are based on your work status. Costs for the vision plan are based on your work status. Remember: Medical, dental, and vision contributions are deducted from each of your biweekly paychecks. To determine your full cost for the year, multiply the rates by 6.

6 Carrier Contact Information For more information about your medical, dental, and vision plans, visit FMRbenefits.com. For general questions or enrollment and eligibility information, call HR Solutions at , Prompt, Monday through Friday, 8:30 a.m. to 8:00 p.m. ET. For detailed coverage information, please contact the plan carrier directly. Carrier contact information appears below and is also available on NetBenefits > Health & Insurance > Quick Links > Contact Directory. AETNA MID-ATLANTIC HMO AND AETNA TEXAS HMO CIGNA HMO CVS CAREMARK PRESCRIPTION DRUG EYEMED VISION FIDELITY HEALTH PLAN (UNITEDHEALTHCARE) HARVARD PILGRIM HMO HEALTHFLEX PPO (UNITEDHEALTHCARE) HUMANA HMO METLIFE DENTAL SELECTHEALTH HMO CIGNA4 ( ) Pre-enrollment: Pre-enrollment: Choose Insight network when searching for a provider Pre-enrollment: Pre-enrollment: *You can link directly to these sites through NetBenefits without entering a separate password. Note: For some websites, login and/or registration may be required. Unless otherwise noted, prospective members can use the phone numbers and websites above for information before enrolling. For more information, visit FMRbenefits.com Have a question? Give us a call at , Prompt FI-H-544A.