MEDICAL SCHEDULE OF BENEFITS HDHP $4,000 PLAN

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1 MEDICAL SCHEDULE OF BENEFITS HDHP $4,000 PLAN HDHP 4000 LIFETIME MAXIMUM BENEFIT CALENDAR YEAR MAXIMUM BENEFIT Unlimited Unlimited CALENDAR YEAR DEDUCTIBLE (combined with Prescription Drug Card Deductible) Single $4,000 $8,000 $10,000 $18,000 CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes Deductibles, Copays, Coinsurance, precertification penalties, includes Prescription Drug Card benefits) Single MEDICAL BENEFITS $6,350 $12,700 $25,000 $35,000 Allergy Serum & Injections Ambulance Services Ground Paid at Participating Provider level of benefits Air Ambulance $200 Copay per trip, then Paid at Participating Provider level of benefits Ambulatory Surgical Center Anesthesiologist Anti-Embolism Garments (e.g. Jobst) $50 Copay per pair, then 3 pairs Cardiac Rehab (Outpatient) Chemotherapy (Outpatient) Chiropractic Care/Spinal Manipulation 20 Visits Diagnostic Testing, X-Ray and Lab Services (Outpatient) Durable Medical Equipment (DME)

2 Emergency Services Emergency Medical Condition Facility Charges Paid at Participating Provider level of benefits, unless otherwise required by law Professional Fees and Ancillary Charges Paid at Participating Provider level of benefits, unless otherwise required by law Non-Emergency Medical Condition Facility Charges Professional Fees and Ancillary Charges Foot Orthotics Age 19 and over - 1 every 12 months; Hearing Aids (including any office visit and any related services, includes cochlear Implants ) Under age 19-1 every 6 months 1 aid per ear per 36-month period Hemodialysis (Outpatient) Home Health Care 60 visits Hospice Care Inpatient then Outpatient Hospital Expenses or Long-Term Acute Care Facility/Hospital (facility charges) Inpatient then Room and Board Allowance Semi-Private Room rate* Semi-Private Room rate* Outpatient *Charges for a private room, that exceeds the cost of a semi-private room, are eligible only if prescribed by a Physician and the private room is Medically Necessary. Infusion Therapy in Facility or Physician s Office Maternity (Professional Fees)* Preventive Prenatal and Breastfeeding Support 100%; Deductible waived

3 (other than lactation consultations) Lactation Consultations 100%; Deductible waived 100%; Deductible waived Breast Pumps 100%; Deductible waived 100%; Deductible waived All Other Prenatal, Delivery and Postnatal Care * See Preventive Services under Eligible Medical Expenses for limitations. Medical Supplies Mental Disorders and Substance Use Disorders Inpatient Combined Calendar Year Maximum Benefit Substance Use Disorders Lifetime then 30 days 90 days Outpatient *Does not apply to office visits for medication management. Morbid Obesity (Surgical Treatment Only) Facility $250 Copay, then 80% after Deductible 30 visits* Professional Services Lifetime 1 Surgical Procedure Nutritional Food Supplements Occupational Therapy (Outpatient) Payable per Calendar Year 60 Visits Physical Therapy (Outpatient) Payable per Calendar Year 60 Visits Physician s Services Inpatient/Outpatient Services Office Visits Physician Office Surgery Preventive Services and Routine Care Preventive Services (includes the office visit and any other eligible item or service billed and received at the same time as any preventive service) Routine Care 100%; Deductible waived Not Covered 100% up to $300 per Calendar Year, then 10% Not Covered

4 HDHP 4000 (includes any routine care item or service not (Deductible waived) otherwise covered under the preventive services provision above) Flu Shots/Pneumonia & Shingles Vaccinations 100%; Deductible waived 100%; Deductible waived Routine Hearing Exam 1 exam Prosthetics (other than bras) Prosthetic Bras 2 bras Psychological and Neuropsychological Testing Radiation Therapy (Outpatient) Rehabilitation Facility then 60 days Skilled Nursing Facility then per 12 Month Period 60 days Speech Therapy (Outpatient) Payable per Calendar Year 60 Visits Surgery (Inpatient) Facility then Professional Services Surgery (Outpatient) Facility Professional Services Temporomandibular Joint Dysfunction (TMJ) $50 Copay per occurrence, then Lifetime : Surgical Procedure Appliances Office Services Transplants (Facility) Urgent Care Facility 1 Surgical Procedure 1 appliance $1,000 Not Covered then $50 Copay per visit, then

5 Wig (see Eligible Medical Expenses) All Other Eligible Medical Expenses $50 Copay per wig, then $50 Copay per wig, then 1 every 24 months $50 Copay per occurrence, then

6 PRESCRIPTION DRUG SCHEDULE OF BENEFITS HDHP $4,000 PLAN BENEFIT DESCRIPTION BENEFIT NOTE: There is no coverage under the Plan for Prescription Drugs obtained from a Non-Participating pharmacy. CALENDAR YEAR DEDUCTIBLE (combined with major medical Deductible) Single CALENDAR YEAR OUT-OF-POCKET MAXIMUM (combined with major medical benefits) (includes Deductible and Copays) Single Retail Pharmacy: 30-day supply Generic Drug Preferred Drug Non-Preferred Drug Preventive Drug $4,000 $8,000* $6,350 $12, % (Deductible waived) Mail Order or Retail Pharmacy: 90-day supply Generic Drug Preferred Drug Non-Preferred Drug Preventive Drug 100% (Deductible waived) Mandatory Generic Program The Plan requires that pharmacies dispense Generic Drugs when available. Should a Covered Person choose a Brand Name Drug rather than the Generic equivalent, the Covered Person will be responsible for the cost difference between the Generic and Brand Name Drug, even if a DAW (Dispense As Written) is written by the prescribing Physician. The Covered Person's share of the Prescription Drug cost does not apply toward the Plan's Out-of-Pocket Maximum.

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