The Belden Medical Plan At a Glance (for the Highmark BCBS Outside of the Richmond area)

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1 The Belden Medical Plan At a Glance (for the Highmark BCBS Outside of the Richmond area) This chart highlights the key features of the Belden Medical Plan, including information about eligibility, enrollment, your benefit options, benefit coverage and costs for the Highmark BCBS Medical Plan. Refer to this booklet and your Summary Plan Description for more details about each of these features. Plan Feature Who Is Eligible When You May Participate When You Can Enroll or Make Changes When Coverage Ends Your Monthly Cost for Medical Coverage Medical Claims Administrator PPO Network Precertification and Medical Case Management Pharmacy Benefit Manager Special Wellness Exam Savings The Belden Health Care Program General Program Information Highlights Any active regular employee who normally works at least 24 hours per week. In addition, your spouse or domestic partner and your dependent children may be eligible for dependent coverage. Special rules for spousal coverage apply. Please see your Human Resources Department for details. As a participant in Belden's Plan C, you may also be eligible to open a Health Savings Account (HSA). To open an HSA, an individual: must be enrolled in only a qualified high deductible health plan, such as Plan C; cannot be covered by any other health insurance coverage; cannot be enrolled in Medicare; and cannot be claimed as a dependent on another person's tax return. Belden does not contribute to employee HSAs, but pays the basic maintenance fees for an active employee's account. If you are an eligible salaried (exempt or non-exempt) employee, you and your eligible dependents may participate in the Plan beginning on your date of hire. If you are an eligible hourly employee, you and your eligible dependents may participate after you complete a 60-day waiting period from your date of hire. Within 30 days from when you are hired or after the 60-day waiting period. During annual open enrollment, typically a two-week period in October or November. Within 30 days of a change in status. You and/or your dependents coverage ends on the earliest of the date: your employment ends, you or your dependents no longer meet the eligibility requirements, you or your dependents fail to make the required contributions, dependent coverage is terminated under the Plan, or the Plan is terminated. Plan A Plan B Plan C Employee Only $144 $101 $66 Employee + Child or Children $308 $235 $148 Employee + Spouse $350 $265 $169 Employee + Family $478 $318 $205 Highmark Blue Shield Highmark Blue Shield CVS Caremark P.O. Box Camp Hill, PA P.O. Box Camp Hill, PA P.O. Box 6590 Lee s Summit, MO If you get an annual physical and biometric screening and your results meet certain criteria, you may be eligible for $20 (employee only) or $40 (employee and spouse) off the regular monthly cost for medical coverage. See your Human Resources Department for details.

2 Annual Deductible Per covered person $400 $800 Family maximum $900 $1,800 Per covered person $600 $1,200 Family maximum $1,200 $3,000 Employee Only $1,300 $2,600 Family $2,600 $5,200 Hospital Copay Per admission Plan A and B Only $250 (Limited to 2 copayments per member per benefit period) (Combined with inpatient mental health and substance abuse.) Annual Out-of-Pocket Maximum (Includes Annual Deductible & Copays) Per covered person $3,200 $6,400 Per family $6,650 $13,300 Per covered person $5,500 $11,000 Per family $11,000 $22,000 Per covered person $5,750 $11,400 Per family $11,500 $22,800 Family deductible administration (Plan C Only) Precertification Requirements Performed by the covered person or the attending physician s or mental health care provider s office. Unlike the PPO plans, the Plan C family deductible must be met by one or more enrolled family members before any individual is deemed to have met their deductible and/or out-of-pocket maximum. You are responsible for pre-certifying all hospitalizations and inpatient surgeries by calling Highmark BCBS at Inpatient Hospital Services Room and board, physician hospital visits, medical services and supplies, lab and x-rays, drugs 80% after annual & hospital deductible 60% after annual & hospital deductible Plan B-PPO 70% after annual & hospital deductible 50% after annual & hospital deductible Plan C-HSA Outpatient Hospital Services Pre-admission/post-operative testing, outpatient or ambulatory surgery, medical services and supplies 80% after annual deductible 60% after annual deductible

3 Emergency Room Care Prescription Drugs Plan A-PPO and B-PPO: Pharmacy Option (up to 30-day supply) Copayment, per prescription: Generic Formulary Brand Non-Formulary Brand Mail Order Option (up to 90-day supply) Copayment, per prescription: Generic Formulary Brand Non-Formulary Brand Generic & Brand prescriptions $100 copay (copay waived if admitted), 80% thereafter $100 copay (copay waived if admitted), 70% thereafter $10 $25 $20 $100 $100 Specialty and Injectable Drugs Plan A-PPO 80% after annual deductible Plan B-PPO Plan C-HSA Wellness Benefits Plans A, B and C: Well-adult care One routine physical exam per year. Female members also may receive one routine gynecological exam per year. Not subject to deductible Not covered Well-child care Routine well child visits or physical exams. Wellness lab tests Including adult and child immunizations, Pap smears, and colon cancer screenings. Also covered are flu shots, mammograms and TB tests. Eye exam One routine eye exam every 24 months. Includes eye refractions and glaucoma testing. $20 copay; maximum allowable expense is $75 before copay. Office Visits - PCP $20 copay 60% after annual deductible $20 copay

4 Office Visits - Specialist $35 copay 60% after annual deductible $35 copay Maternity Care Prenatal/postnatal office visits and physician/hospital services for pregnancy or delivery Plan A-PPO 80% after annual & hospital deductible 60% after annual & hospital deductible Plan B-PPO 70% after annual & hospital deductible 50% after annual & hospital deductible Plan C-HSA Private Duty Nursing (benefit limited to $20,000 annually) Skilled Nursing Facility (up to 100 days per benefit period) Home Health Care (limited to 100 days per year) Hospice Care Speech therapy (subject to limitations) Outpatient Occupational/Physical Therapy (Limited to 20 visits per condition per benefit period) Organ Transplants (Same as inpatient hospitalizations. Subject to Case Management.) Organ transplants must be pre-certified by calling Highmark BCBS at

5 Chiropractic Treatment (Limited to 25 visits per benefit period) Durable Medical Equipment/Prosthetics and Orthotics Ambulance Services 80% after annual deductible Mental Disorders/Substance Abuse Services Plan A-PPO: Inpatient (precertification required) 80% after $250 copayment & annual deductible 60% after annual & hospital deductible Outpatient $20 copay, then 60% after annual deductible Plan B-PPO: Inpatient (precertification required) 70% after $250 copayment & annual 50% after annual & hospital deductible deductible Outpatient $20 copay, then Plan C-HSA: Inpatient (precertification required) Outpatient