$250 $750 $1,500 Family

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1 Personal Choice Trinity Health Traditional PPO Personal Choice,our popular Preferred Provider Organization (PPO), gives you freedom of choice by allowing you to choose your own doctors and hospitals. You can maximize your coverage by accessing your care through Personal Choice's large network of hospitals, doctors and specialists, or by accessing care through preferred providers that participate in the BlueCard PPO program. Of course, with Personal Choice, you have the freedom to select providers who do not participate in the Personal Choice network or BlueCard PPO program. However, if you receive services from out-of-network providers, you will have higher out-of-pocket costs and may have to submit your claim for reimbursement. With Personal Choice... You do not need to enroll with a primary care physician You never need a referral In-Network Out-of-Network Benefits Tier l: Trinity Health Facilities and Tier ll: PPO In-Network Out-of-Network Facility and Aligned Professional Providers + Facility and Professional Professional Providers 1 Providers DEDUCTIBLE * Individual $250 $750 $1,500 Family $500 $1,500 $3,000 COINSURANCE 90% 80% 60% OUT-OF-POCKET MAXIMUM * (Deductibles, copayments, and coinsurance amounts apply to maximum) Individual Family $2,500 $4,750 $9,500 $5,000 $9,500 $19,000 LIFETIME MAXIMUM Unlimited Unlimited Unlimited DOCTOR'S OFFICE VISITS Primary Care Services $20 copayment, no deductible $30 copayment, no deductible Specialist Services $30 copayment, no deductible $40 copayment, no deductible PREVENTIVE CARE FOR ADULTS AND CHILDREN 100%, no deductible 100%, no deductible PEDIATRIC IMMUNIZATIONS 100%, no deductible 100%, no deductible ROUTINE GYNECOLOGICAL EXAM/PAP 2 routine exam/pap test per calendar year for women 100%, no deductible 100%, no deductible of any age 2 ROUTINE MAMMOGRAM 1 baseline exam for women age 35-39; 1 exam per 100%, no deductible 100%, no deductible calendar year for women age 40 and up 2 DIAGNOSTIC MAMMOGRAM NUTRITION COUNSELING FOR WEIGHT MANAGEMENT 100%, no deductible 100%, no deductible 6 visits per calendar year 2 ROUTINE HEARING EXAM 100%, no deductible 100%, no deductible 1 exam per calendar year 2 OUTPATIENT LABORATORY/PATHOLOGY MATERNITY (Mom & Baby's claims are processed separately under their own files and both may be subject to the Deductible and OOP Max) First OB Visit $20 copayment, no deductible $30 copayment, no deductible + Your in-network benefits offer both Tier 1 & Tier 2 facilities and providers. Tier 1 (Trinity Health Preferred network) providers are facilities or physicians aligned with our organization that provide you with the most cost-effective care. For services unavailable through Tier 1 providers, select IBC Network providers will be available at the Tier 2 benefit level. Tier 2 includes select IBC Network providers (facilities and physicians) not listed under Tier 1. Tier 2 providers can save you money, but not as much as using our Tier 1 network. 1 Non-Preferred Providers may bill you for differences between the Plan allowance, which is the amount paid by Independence Blue Cross (IBC), and the actual charge of the provider. This amount may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC's fee schedule, the payment is based on 50% of the actual charge of the provider. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider. 2 Combined all tiers * Amounts cross-accumulate across Trinity Health Network, IBC Network & Out-of-Network tiers. Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Crossindependent licensees of the Blue Cross and Blue Shield Association. 10/17 - PA Trinity Trad PPO PHO

2 In-Network Out-of-Network Benefits Tier l: Trinity Health Facilities and Tier ll: PPO In-Network Out-of-Network Facility and Aligned Professional Providers + Facility and Professional Professional Providers 1 Providers MATERNITY (Mom & Baby's claims are processed separately under their own files and both may be subject to the Deductible and OOP Max) Pre-Natal and Post-Natal care for subsequent physician office visits including physical exams of the pregnant woman (maternal weight, blood pressure and fetal heart rate check) Hospital Delivery and Nursery Care High Risk Specialist Visits Ultrasounds and Pregnancy Diagnostic Lab Tests Anemia Screening and Gestational Diabetes Screening Amniocentesis (Professional Charges) Amniocentesis (Facility Charges) 100%, no deductible 100%, no deductible 90%, $500 copayment per admission 4, then 80% $1,000 copayment per $30 copayment, no deductible $40 copayment, no deductible 100%, no deductible 100%, no deductible $50 copayment, then 90% $100 copayment, then 80% $200 copayment, then 60% INPATIENT HOSPITAL SERVICES 5 Facility 90%, $500 copayment per admission 4, then 80% $1,000 copayment per Physician/Surgeon INPATIENT HOSPITAL DAYS OUTPATIENT SURGERY 5 Facility $50 copayment, then 90% $100 copayment, then 80% $200 copayment, then 60% Physician/Surgeon EMERGENCY ROOM - Qualified medical emergency (copayment waived if admitted) $100 copayment, no deductible $100 copayment, no deductible $100 copayment, no deductible EMERGENCY ROOM - Non emergent use $100 copayment, then 90% after $100 copayment, then 80% $100 copayment, then 60% deductible URGENT CARE CENTER $35 copayment, no deductible $35 copayment, no deductible $35 copayment, no deductible AMBULANCE Emergency 90%, 80%, 80%, Non-Emergency 90%, 80%, 80%, OUTPATIENT X-RAY/RADIOLOGY Routine Radiology/Diagnostic MRI/MRA, CT/CTA Scan, PET Scan BARIATRIC SURGERY Covered at Trinity Health Facilities and Blue 90%, 80%, Not Covered Distinction Center ONLY TRANSPLANTS Covered at Trinity Health Facilities, Blue Distinction 90%, 80%, Not Covered Center and Blue Distinction Center Plus ONLY THERAPY SERVICES Physical, Speech and Occupational 60 visits maximum per therapy per calendar year 2 Cardiac Rehabilitation 36 visits maximum in a 12 week period 2 Pulmonary Rehabilitation 36 visits maximum per calendar year 2 Orthoptic/Pleoptic 8 sessions lifetime maximum 2 SPINAL MANIPULATIONS, including CHIROPRACTIC CARE 90%, 80%, 20 visits per calendar year 2 INJECTABLE MEDICATIONS Standard Injectables Biotech/Specialty Injectables CHEMO/RADIATION DIALYSIS 90%, 80%, Not Covered OUTPATIENT PRIVATE DUTY NURSING 90%, 80%, 960 hours maximum per calendar year 2 SKILLED NURSING FACILITY 90% $500 copayment, then 80% $1,000 copayment, then 60% 120 days maximum per calendar year 2 HOME HEALTH CARE 90%, 80%, 120 visits per calendar year 2 + Your in-network benefits offer both Tier 1 & Tier 2 facilities and providers. Tier 1 (Trinity Health Preferred network) providers are facilities or physicians aligned with our organization that provide you with the most cost-effective care. For services unavailable through Tier 1 providers, select IBC Network providers will be available at the Tier 2 benefit level. Tier 2 includes select IBC Network providers (facilities and physicians) not listed under Tier 1. Tier 2 providers can save you money, but not as much as using our Tier 1 network. 1 Non-Preferred Providers may bill you for differences between the Plan allowance, which is the amount paid by Independence Blue Cross (IBC), and the actual charge of the provider. This amount may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC's fee schedule, the payment is based on 50% of the actual charge of the provider. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider. 2 Combined all tiers 3 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental illness and substance abuse services. 4 Copayment waived if readmitted within 10 days of discharge 5 Effective 8/1/16 Children's Hospital of Philadelphia (CHOP), St. Christopher's, and Nemours DuPont Children's Hospital will be added to Trinity Health Tier 1 Facility Network.

3 Benefits In-Network Tier l: Trinity Health Facilities and Aligned Professional Providers + Tier ll: PPO In-Network Facility and Professional Providers Out-of-Network Out-of-Network Facility and Professional Providers 1 HOSPICE 100%, no deductible 100%, no deductible DURABLE MEDICAL EQUIPMENT 90%, 90%, after Tier 1 deductible** PROSTHETICS 90%, 90%, after Tier 1 deductible** WIGS 90%, 90%, after Tier 1 deductible** MENTAL HEALTH CARE ** Outpatient Inpatient SERIOUS MENTAL ILLNESS ** Outpatient Inpatient ALCOHOL AND DRUG ABUSE TREATMENT ** Detoxification Outpatient/Partial Services Inpatient Rehabilitation $20 copayment, no deductible $20 copayment, no deductible 90%, 90% after Tier 1 deductible ** $1,000 copayment per $20 copayment, no deductible $20 copayment, no deductible 90%, 90% after Tier 1 deductible ** $1,000 copayment, then 60% 3 90%, no deductible 90% after Tier 1 deductible ** $1,000 copayment per $20 copayment, no deductible $20 copayment, no deductible 90%, no deductible 90% after Tier 1 deductible ** $1,000 copayment per + Your in-network benefits offer both Tier 1 & Tier 2 facilities and providers. Tier 1 (Trinity Health Preferred network) providers are facilities or physicians aligned with our organization that provide you with the most cost-effective care. For services unavailable through Tier 1 providers, select IBC Network providers will be available at the Tier 2 benefit level. Tier 2 includes select IBC Network providers (facilities and physicians) not listed under Tier 1. Tier 2 providers can save you money, but not as much as using our Tier 1 network. 1 Non-Preferred Providers may bill you for differences between the Plan allowance, which is the amount paid by Independence Blue Cross (IBC), and the actual charge of the provider. This amount may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC's fee schedule, the payment is based on 50% of the actual charge of the provider. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider. 3 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental illness and substance abuse services. ** Tier 1 (Trinity Health Network) deductible & out-of-pocket maximum apply for mental health services, substance abuse services, durable medical equipment, prosthetics and wigs rendered in Tier 2 (IBC Network) What Is Not Covered? Services not medically necessary Cancer Treatment Centers of America (CTCA): there is no Network or Out-of-Network coverage for both health care services provided by the facility; and health care services provided by physicians and other health care professionals at any of these facilities. Expenses related to organ donation for non-member recipients Assisted fertilization techniques such as artifical insemination, in-vitro fertilization, GIFT, and ZIFT Self-injectable drugs Routine foot care, unless medically necessary or associated with the treatment of diabetes Contraceptives (except when medically necessary) Routine physical exams for non-preventive purposes such as insurance or employment applications, college, or premarital examinations Immunizations for travel or employment Service or supplies payable under Workers' Compensation, Motor Vehicle Insurance, or other legislation of similar purpose Cosmetic services/supplies Vision care (except as specified in a group contract) Dental care, including dental implants, and nonsurgical treatment of temporomandibular joint syndrome (TMJ) Music therapy, equestrian therapy and hippotherapy Treatment of sexual dysfunction not related to organic disease except for sexual dysfunction resulting from injury Alternative therapies/complementary medicine Services or supplies which are experimental or investigative except routine costs associated with clinical trials Foot orthotics, except for orthotics and podiatric appliances required for the prevention of complications associated with diabetes Elective abortions, voluntary sterilizations, and reversal of voluntary Sterilizations Hearing Aids, hearing examinations/tests for the prescription/fitting of hearing aids and cochlear electromagnetic hearing devices 3D Mammography Out of Network Habilitative PT/OT/Speech therapy services This summary represents only a partial listing of the benefits and exclusions of the Personal Choice Program described in this summary. If your employer purchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your contract/member handbook carefully for a complete listing of the terms, limitations and exclusions of the program. If you need more information, please call (outside Philadelphia) or (if calling within the Philadelphia area).

4 Certain services require preapproval/precertification by the health plan prior to being performed. To obtain a list of services that require authorization, please log on to or call the phone number that is listed on the back of your identification card. Prescription Drugs Administered directly by CVS Caremark CVS CAREMARK MEMBER SERVICES Retail 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $10 copay 20% with $30 minimum and $80 maximum 40% with $60 minimum and $100 maximum Ministry owned on-site pharmacies 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name Ministry owned on-site pharmacies 90-day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $8 copay 16% with $24 minimum and $64 maximum 32% with $48 minimum and $80 maximum 100% after $24 copay 16% with $72 minimum and $192 maximum 32% with $144 minimum and $240 maximum Mail Order 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $25 copay 20% with $75 minimum and $200 maximum 40% with $150 minimum and $250 maximum 50% coinsurance for infertility drugs dispensed through pharmacy (no maximum) If the brand drug has a specific equivalent generic drug available and the plan participant receives the brand, then in addition to the copay, the plan participant must also pay the difference between the ingredient cost of the brand drug and the generic drug. Specialty medications must be filled at a Trinity Health pharmacy or through the CVS Caremark Specialty program; prescriptions limited to a 30 day supply. Mandatory Maintenance is required for each maintenance medication after an initial retail prescription and two refills. Pharmacy copays and coinsurance will track to Tier 2 out-of-pocket max. Coverage of Preventive Services Medications (under the Patient Protection and Affordable Care Act (No copay): Prescription required - Iron supplements (Ages 6 months through 12 months), Oral Fluorides (Ages 5 and younger), Aspirin (ages males, ages females), Folic Acid (women age 55 and younger), Immunizations, Vitamin D (Ages 65+), Bowel Preparation Medications Prescription only (ages 50 through 74), and Breast Cancer Drugs (female age 35+) Prescription required (total 168-day supply) - Tobacco Cessation - Nicotine replacement products, including Nicotine patch, gum & lozenges. Also covers generic Zyban or Chantix

5 Exclusions: Cosmetic medication Anti-wrinkle agents, Hair growth / removal, etc Erectile Dysfunction (ED) Medications Non-Sedating Antihistamine (NSA) Drugs Compound pain patches and bulk powders Hypoactive Sexual Desire Disorder (Addyi) The following is a list of the drugs that need prior authorization to be covered (not intended to be an allinclusive list): (Your physician must call to obtain approval for a period of up to one year) Topical acne Oral contraceptives Compounds $300 an greater Specialty medications Anti-obesity agents Narcolepsy Anabolic steroids

6 The following is a list of most but not all of the drugs that have a quantity limit imposed: Flu medication Migraine medication Due to the large number of available medicines, this list is not all inclusive. Please note that this list does not guarantee coverage and is subject to change. Your prescription benefit plan may not cover certain products or categories, regardless of their appearance on this list. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. For a complete description of benefits please see the applicable summary plan descriptions. If there is a discrepancy between this summary and any applicable plan document, the plan document will control. More information is available through Caremark.com to help you manage your prescription drug program. You will be able to locate a pharmacy, order mail service refills, track mail service orders, and ask questions. For additional information contact Caremark at