Traditional Plan Inside UHACO Effective January 1, You pay: $600 $1,200 $2,200

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1 Traditional Plan Inside UHACO Effective January 1, 2016 Calendar Year Deductible 1 Per Individual Per Family Member s Coinsurance 2 Out-of-Pocket Maximum 4 (includes deductible, coinsurance and copayments) Per Individual Per Family Maximum Age for Eligible Children Tier 1 (UHACO Network) $600 $1,200 Tier 3 (Out-of-Network) $2,000 $4,000 15% after deductible 50% of R&C 3 after deductible $2,200 $11,500 $4,400 $23,000 Age 26 (Eligible Children are covered until the end of the month the child reaches age 26) Covered Services Covered Services Tier 1 (UHACO Network) Tier 3 (Out-of-Network) Preventive Services (Note: only available when accessed through a PCP or OB/GYN) General Physical Exam (includes routine EKG, complete blood count, comprehensive metabolic panel, 0% no deductible 50% of R&C after deductible urinalysis) Routine Preventive Screenings (Cholesterol test, Bone Density Test, Pelvic Exam, Pap Test, Prostate Specific Antigen Test, Routine Colorectal Cancer Screening, Tuberculin Skin, TSH) Routine Mammogram Well Baby/Well Child Care Visits Immunizations 1 One person on the family plan only has to meet the individual amount listed. Co-payments do not apply to the Deductible. 2 Coinsurance is the percentage share of costs you pay after you meet the Deductible. 3 You will be responsible for paying any amount in excess of R&C in addition to the Deductible and Coinsurance. 4 Annual out-of-pocket is the maximum you pay between the deductible, coinsurance and co-payments before expenses are paid at 100% in-network. One person on the family plan only has to meet the individual amount listed. This includes deductibles and coinsurance, co-payments and excludes Prescription Copayments and Coinsurance, Infertility treatment coinsurance and amounts over Reasonable and Customary Charges. Complete benefit descriptions, services requiring Prior Authorization and exclusions are contained in the UH Summary Plan Description (SPD) and any applicable Summary Material Modification. In situations where there are differences between this Schedule of Benefits and the Summary Plan Description, the SPD will govern.

2 Covered Services Tier 1 (UHACO Network) Tier 3 (Out-of-Network) Routine Vision Exam (One exam per benefit period) 0% no deductible 0% no deductible 5 Emergency/Urgent Care Services Emergency use of the Emergency Room Emergency Room Physicians Urgent Care Services $250 Co-payment per visit (waived if admitted/observation) $250 Co-payment then 0% of R&C per visit (waived if admitted/observation) 0% no deductible 0% of R&C no deductible $40 Co-payment per visit 50% of R&C after deductible Medical Services Primary Care Office Visits Additional Services Performed during the PCP Visit Specialist Office Visits Additional Services Performed during the Specialist Visit Inpatient Physician Services Outpatient Physician Services Diagnostic X-ray & Laboratory Services $25 Co-payment per visit 50% of R&C after deductible Facility Services Inpatient Services Outpatient Services Outpatient Surgery Center Other Services Ambulance Transport (for emergent medical transport and medically necessary non-emergent transport) 0% no deductible 5 You will be responsible for paying any amount in excess of 100% of R&C in addition to the deductible and coinsurance.

3 Traditional Plan Inside UHACO Effective January 1, 2016 Covered Services Tier 1 (UHACO Network) Tier 3 (Out-of-Network) Bariatric Surgery (limited to $10,000/lifetime) Chiropractic Services (limited to 20 visits per benefit period) Additional Services Performed during the Chiropractic visit Durable Medical Equipment Home Health Care (limited to 50 visits per benefit period; includes RN, physical, occupational and speech therapy) Hospice Services Inpatient Rehabilitation (limited to 60 days per benefit period) Rehabilitative Services (Physical//Occupational therapy limited to 30 visits per benefit period combined; Speech therapy limited to 30 visits per benefit period) Skilled Care Facility (limited to 90 days per benefit period) Transplants $25 Co-payment per visit 50% of R&C after deductible Mental Health and Substance Abuse/Alcohol Abuse Services Inpatient Outpatient Partial Hospitalization, Intensive Outpatient Services and Ambulatory Detoxification (see SPD for details) Residential Not Covered Reproductive Care Services Pre and Postpartum Maternity Care Visits $25 Co-payment (initial visit only) 50% of R&C after deductible Complete benefit descriptions, services requiring Prior Authorization and exclusions are contained in the UH Summary Plan Description (SPD) and any applicable Summary Material Modification. In situations where there are differences between this Schedule of Benefits and the Summary Plan Description, the SPD will govern.

4 Covered Services Tier 1 (UHACO Network) Tier 3 (Out-of-Network) Pre and Postpartum Maternity Services Inpatient Delivery Charges Childbirth Education classes Contraceptive Implants and Devices Infertility Diagnostics Infertility Treatments (limited to $10,000/lifetime; limited to MacDonald and IVF Program) Hearing Aid Services Hearing Aid Evaluation Hearing Aid Test Hearing Aid (limited to one per ear every four benefit periods) Cochlear Implants Not Covered 50% after deductible Not Covered $25 Co-payment per visit 50% of R&C after deductible

5 Traditional Plan Inside UHACO Effective January 1, 2016 Prescription Drug Services (Administered by CVS Caremark) Calendar Year Deductible None Prescription Drug Out-of-Pocket Maximum Per Individual Per Family Network Retail (30 day supply/prescription) Network Mail Order or retail & CVS/ pharmacy (90 day supply/prescription) Non Network Retail Smoking Cessation Drugs Immunizations Infertility Drugs Diabetic Supplies ( 200 meter strips per individual per month ; additional meter strips covered as needed with prior authorization) Generic Drug Program Prior Authorization $2,500 $5,000 Generic Formulary Brand Name Non Formulary Brand Name Prescription Prescription 30% 50% $15 Co-payment* $30 minimum* $70 minimum* $75 maximum $200maximum 20% 50% $30 Co-payment* $60 minimum* $150 minimum* $150 maximum $400 maximum Not Covered Covered 100% for approved dosage levels for tobacco cessation treatment for the following: Buproprion (HCL Tab SR 12HR 150 MG), Chantix, generic nicotine patches, gum, or lozenges. Covered at 100% shingles for members 50 years of age and older; flu and pneumonia immunization only when administered by a pharmacist. 50% Paid by Member up to a lifetime maximum benefit of $5,000. This coinsurance does count toward the annual maximum out-of-pocket limit. Meter strips, lancets, syringes, urine test strips and one blood glucose meter per year will be covered at one Generic copayment per Prescription. Generic Drugs will be dispensed whenever permitted by state and federal law. If the Member requests a Brand Name Drug when a Generic equivalent is available, the Member will be charged the generic copayment plus the difference in cost between the Brand Name Drug and the Generic Drug. See Step Therapy for information about using a generic drug first before certain brand drugs. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. Prior authorization must be obtained by your physician in order for you to receive benefit for these drugs. Drug classes with Prior Authorization may include but may not be limited to: ADHD (>19y/o), Nacolepsy, Anacolic Steroids, Pain (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys), Testosterone Products, Acne (>35 y/o). Complete benefit descriptions, services requiring Prior Authorization and exclusions are contained in the UH Summary Plan Description (SPD) and any applicable Summary Material Modification. In situations where there are differences between this Schedule of Benefits and the Summary Plan Description, the SPD will govern.

6 Prescription Drug Services (Administered by CVS Caremark) Quantity Limits Certain prescription drugs have specific Quantity Limits per prescription per month. Step Therapy Drug classes with a Quantity Limit include but may not be limited to: Antiemetic (nausea), Antimigraine Influenza (Tamiflu, Relenza). Certain prescriptions drugs require Step Therapy, which is a process where you may be required to first try an alternative therapy before your prescription benefits may be used toward the requested medication. You must first try generic drugs, if available, before using certain brand drugs. Drug classes with Step Therapy include: Solodyn Drug classes with Generic Step Therapy include but may not be limited to: ARB/Combos (blood pressure), bisphosphonates, HMGs (cholesterol), Sleep agents, PPIs (acid reflux), NSAIDs, Nasal Steroids, SSRIs/SNRIs, (depression/pain), Triptans (migraine), Urinary Antispasmodics (overactive bladder), Fibrates (cholesterol), BPH (enlarged prostate), Prostaglandin Analogs (glaucoma), Acne, Asthma/COPD Coverage Exceptions For certain medications covered at zero cost per provisions related to Affordable Care act also known as Health Care Reform (HCR), a member can receive preventive services or a contraceptive product for a $0 member cost share. Medications covered at no copay under HCR include preventive services medications (Aspirin, Folic Acid, Fluoride, Smoking Cessation Drugs, Etc) and contraceptive agents. Specialty Preferred Drug Therapy In select categories of specialty medications (infertility, TNG inhibitors and growth hormones), a member must try a preferred product before having access to a nonpreferred product. Your physician can contact CVS Caremark for coverage of a nonpreferred product should clinical evidence suggest that drug is medically necessary. Contraceptives Contraceptive injectables, oral and patch are covered. Contraceptive implants and devices are covered under the medical benefit. *If the full cost of the drug is less than the minimum, you pay the full cost of the drug. A 90-day supply of maintenance medications may be filled at either mail order or a CVS Caremark retail store.