For questions about plan information in this brochure, please contact our Account Coordinator below.

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3 3 Table of Contents 4 About SIHO 5 Choice, HRA, and HSA Plans 6 What We Offer 8 Prescription Coverage 9 Precertification Information 10 HRA Overview 11 HSA Overview IRS Qualifying Expenses 14 Eligibility Guidelines 15 Information Available on the SIHO Website 16 Preventive Health Benefit 18 Provider Search Landmark Combined 20 3-Tier Landmark Combined Plans 32 Provider Search Landmark 33 2-Tier Landmark Plans For questions about plan information in this brochure, please contact our Account Coordinator below. Carolyn Dailey carolyn.dailey@siho.org 3

4 You demand more choices and more value from your health plan. SIHO can meet this demand by providing a wide range of health plans specifically designed for your business. In addition to our comprehensive health plans, SIHO also provides other employee benefit programs such as Flexible Spending Account administration, COBRA administration, Dental, Vision and Life Insurance. We are committed to meeting the needs of our customers through the quality of our products and the services we deliver. SIHO offers coordinated health insurance coverage and related services to businesses. You can choose from a broad range of cost-effective and flexible health plans for your employees. Working with brokers and consultants, SIHO is dedicated to servicing all aspects of an employer s group health plan. Managing complex administrative requirements while simultaneously providing first-class service to our customers is the SIHO advantage. Optimized Products Population Health & Wellness ACO Development & Administration Employer Based Clinics Employer Direct Contracting Customized Hospital Reporting TPA (Claims Administration) Provider Management How can I help SIHO provides friendly and professional customer service with a personal you today? touch to all our clients. SIHO's Client Service Representatives are trained to answer questions pertaining to the health plans, including benefit coverage and claim inquiries. With offices located in Columbus and Seymour, IN, SIHO is able to provide local, reliable customer service to all of our members. SIHO s employees are highly trained with access to the latest technology to provide fast and accurate administration of claims payment, issuance of ID cards and policies. 4

5 SIHO Insurance Services offers an employee benefits package that will provide your employees with quality insurance coverage. Our Choice, HRA, and HSA products feature comprehensive coverage including: Physician Services Primary Care Physician Office Visits covered with only a copayment (not available on HRA and HSA Plans) Preventive Health Benefit Inpatient and Outpatient Hospital Services Maternity Coverage Radiology and Laboratory Services Disease and Case Management Programs Prescription Coverage Including Mail Order Service Access to SOLUTIONS Mental Health and Substance Abuse Services (not available on HSA Plans) SIHO s of more than 30,000 doctors, hospitals and other providers Life Insurance Coverage While Traveling Emergency and Urgent Care Coverage 5

6 The SIHO Medical Management program creates cost savings for our employers through chronic disease management, case management and utilization review. These services are performed in-house by SIHO s medical staff and are integrated into all benefit plans. SIHO s staff of Physicians, Nurse Practitioners and Registered Nurses ensure medical services are clinically appropriate, meet the standards of care in the community and are done in the most cost-effective manner. SIHO s medical staff provides expert medical opinions and information to improve the quality of care for SIHO members. SIHO also provides follow-up contacts, when needed, to ensure proper care is being followed. Some benefits require precertification from SIHO Medical Management. Benefits which require precertification include*: All hospital inpatient treatments and certain outpatient procedures Speech Therapy Durable Medical Equipment (DME) purchases over $750 and all DME rentals Specialty Drugs, except for insulin Radiation Therapy, Chemotherapy and Dialysis Failure to obtain precertification could result in a reduction of benefits for that service or procedure up to a penalty of fifty percent (50%) of the Prevailing Rate. Members are responsible for obtaining precertification for services from a non-network provider. A core benefit of Landmark Choice plans is wellness coverage. SIHO understands the importance of keeping you, your employees and their families healthy. Preventive care is covered for all members, which includes well baby care for our youngest members. SIHO has enhanced its Preventive Health Benefit to include physicals every year for all of our members, as well as adding coverage for Cholesterol Screenings, Lipid Panel, Blood Glucose Testing and Osteoporosis Screenings. A full listing of SIHO s Preventive Health Benefit can be found on pages of this booklet. SIHO uses many national health care criteria to create our Preventive Health Benefit standards and recommendations. Our Quality Management Committee reviews preventive care services every year and updates these guidelines as needed. With its emphasis on wellness, Landmark Plans are an investment in your employees health. A healthy start is important for both the expectant mother and the newest addition to the family. SIHO provides coverage to expectant mothers before and after delivery. Covered services include: office visits, services prior to birth, delivery and follow-up care. Newborns receive coverage for the first 30 days after birth. Parents must notify SIHO of the new addition to the family within those 30 days to ensure continued coverage. 6

7 SIHO encourages members to establish a relationship with a primary care physician (family practice, pediatrics and internal medicine). When members see their primary care physician, they pay an office copay (or deductible and coinsurance on HRA and HSA Plans) and the physician then files the claim directly with SIHO. We make the process simple for you and your employees. When members need to see a specialist physician, they pay an office copay (or deductible and coinsurance on HRA and HSA Plans) to cover the office visit. Any ancillary services provided during the visit, such as radiology or laboratory tests, are subject to coinsurance. To find a participating Provider, go to and click on the blue Provider Directory link. You can also call SIHO Member Services at within the Columbus, Indiana calling area, or toll-free Group life insurance coverage is offered as an option for groups over 50 employees. The standard benefit is $15,000 for each employee plus $15,000 AD&D coverage. Dependent life insurance is also available upon the employer s request. Landmark Combined members pay a $5 copay for allergy Injections from an in-network provider. This benefit will help control out-of-pocket expenses for members. HRA and HSA plans pay deductible and coinsurance. Even everyday obstacles can become too much to bear for some people. SIHO has included mental health and substance abuse benefits in our Landmark Choice and HRA plans through SOLUTIONS, an employee assistance program. SOLUTIONS is a service of Quinco Behavioral Health Systems, which is a private, not-for-profit behavioral health organization. The enhanced mental health and substance abuse benefit offers behavioral health care assistance in the identification and resolution of problems that members face in their everyday lives, including marital, family, drug abuse, work and school-related, depression, stress and anxiety (HSA plans use the SIHO, instead of the Solutions for Mental Health Benefits). If you are traveling and require emergency care outside the Landmark Combined network, covered services are paid at in-network levels. If you are traveling or attend school outside the Landmark Combined network and are in need of routine medical care, covered services are paid at out-of-network levels; in most cases, you would benefit from a network discount. The last thing you should think about during a medical emergency is if your insurance will cover the cost of an emergency room visit. Landmark Plans cover emergency and urgent care services. If hospital admission is required, SIHO must be notified within 48 hours or as soon as reasonably possible. Copays are waived if you are admitted to the hospital directly from the Emergency Department. 7

8 Prescription Drug coverage is an important part of any health plan. Plans allow members to purchase prescription medications at a local retail pharmacy, as well as through the mail order service. Retail Services A great way to get short-term medications is through your local pharmacy. Most national drugstore chains and independently owned pharmacies are contracted with SIHO. Mail Order Service Another way to receive your medications is through our mail order program. Utilizing the Mail Order Service saves you time and money by receiving 90 days of medication for approximately the same cost as 75 days of medication from a participating retail pharmacy. More importantly, mail order service is the most convenient method of receiving maintenance medications. Once set up, your medicine will arrive automatically, saving you time and the inconvenience of visits to the pharmacy. HSA plans pay 3 times retail cost for mail order. Birth Control All birth control prescribed by your physician, including oral medication, injectables and other prescribed forms are covered under the plans; most forms are covered by the Preventive Health Benefits (PHB) at no cost. Chantix Smoking Cessation Prescription Chantix (varenicline) is non-nicotine prescription medicine specifically developed to help adults quit smoking. Chantix contains no nicotine, but targets the same receptors that nicotine does. Chantix is believed to block nicotine from these receptors. It is the only prescription treatment of its kind. At the end of 12 weeks of using Chantix, 44% of those using the drug were able to quit smoking. It has also been shown to help reduce the urge to smoke. If you are ready to quit smoking, please contact your physician and ask about Chantix. Chantix is covered under the PHB at no cost. SIHO s prescription drug coverage is managed by Caremark, the recognized leader in pharmacy benefit management (PBM). Members can review their prescription drug activity and cost, learn about various health conditions and access self-care centers. Members can also check drug prices at any participating pharmacy. 8

9 SIHO requires that the following services be pre-certified: Members are responsible for obtaining precertification for services from a non-network provider. Failure to obtain precertification could result in a reduction of benefits for that service or procedure up to a penalty of fifty percent (50%) of the Prevailing Rate. Any inpatient admission (long term acute/sub-acute/rehab/skilled nursing facilities) Mental health and substance abuse, intensive outpatient programs or partial hospitalizations Home health care Durable Medical Equipment (purchase over $750 and all rentals) Hospice care Transplant evaluations and procedures Specialty drugs, excluding insulin Oncology services (chemotherapy and radiation) Applied Behavioral Analysis therapy Dialysis Speech therapy Procedures performed with a letter of necessity from a physician 9

10 A health reimbursement arrangement starts out as a financial commitment from the employer to the employee; i.e., the employer will pay the first $750 of medical expenses for the employee each year. If the employee incurs no claims, the employer does not make any payment. However, this obligation generally carries over to the next year and is added to another $750 commitment for year two. HRAs are generally paired with a higher deductible health plan whose structure can be very flexible, including co-payments for certain services. HRAs are not portable; any balances are forfeited if an employee leaves the organization. Although HRAs can be used to cover the very broad list of IRS qualified medical expenses, most employers limit their use to only services covered by the higher deductible health plan. Claims must be submitted and substantiated to be paid from the HRA. Remember that the cost is always lower when members use a participating provider! The HRA is designed to be easy for both the member and employer. SIHO offers several HRA design variations to meet the needs of most employers. They each have differences in deductibles, coinsurance, co-pays and suggested HRA funding amounts. It is important to remember that the HRA has two parts: a Health Plan and a Health Reimbursement Account. The HRA is to be used to pay for services covered under the health plan that are subject to the deductible or coinsurance. The HRA cannot be used to cover co-payments. The HRA consists of two parts: 1. An affordable health plan that provides comprehensive coverage for office visits, preventive care, prescription drugs, hospital costs and physician services. 2. A Health Reimbursement Account funded by the employer which can be used to pay for services that are the responsibility of the member, i.e., subject to deductible and coinsurance. If the member does not use any or all of their dollars, they roll over to the next year and will accumulate to provide greater financial protection! 10

11 A Health Savings Account (HSA) can be viewed much like a medical IRA. It is a tax advantaged savings account that individuals can use to pay for qualified health care expenses, both now and in the future. As employers continue to migrate to ever higher deductible plans, it makes sense to consider structuring the High Deductible Health Plan (HDHP) so that employees can benefit from the advantages of an HSA. HSAs are physical accounts established at a bank, credit union or insurance company. In order to establish the HSA, the consumer must be covered by a federally qualified HDHP. The structure of the HDHP is set by the U.S. Treasury with minimum deductibles and limits on out-of-pocket maximums. Employees and/or employers can contribute to the HSA, subject to an annual maximum. The accounts are portable and remain with the employee, even if they change jobs. Withdrawals from the HSA can be made for any IRS qualified medical expense, the list of which is very broad and includes dental and vision care. This section can be found on page 14. The consumer does not need to submit claims or receipts to make a withdrawal; it is an honor system where the consumer needs to keep receipts, should they be audited by the IRS. The HSA is part of popular movement towards Consumer Directed Health Plans (CDHPs). They include both HSAs and Health Reimbursement Arrangements (HRAs). Both combine a higher deductible health plan with a personal health care account that the member controls. Unused personal health care account dollars accumulate. Members have the financial incentive to be better health care consumers who will seek out information on health and wellness, as well as the cost and quality of healthcare services. 11

12 The HSA is designed to be easy for both the member and employer. SIHO offers several HSA design variations to meet the needs of most employers. employer. Deductibles Coinsurances Suggested HSA funding amounts by the employer An employer may choose to offer their employees only an HSA plan design. Alternatively, the employer may offer an HSA plan together with a more traditional plan to better meet the needs of all employees. Due to the HSA plans having higher deductible levels than more traditional plans, the premium or expected claims for these plans are typically much less. Employers are strongly encouraged to use a large percentage of these savings to help fund each employee s HSA. Over the long run, HSAs save money by getting people engaged as health care consumers, not through simple cost-shifting. This can only be achieved if the employees have money in their HSAs that they are trying to conserve and accumulate. 12

13 Eligible Medical Expenses (For Health Savings Account [HSA] Distributions) Eligible Eligible Over-the Over-the Counter Counter Drugs* Drugs* (for (for HSA Distribution) *requires a physicians a physicians prescription prescription Ineligible Medical Expenses Ineligible Over-the-Counter Drugs 13

14 All medical and pharmacy quotes are issued contingent upon SIHO being the only medical coverage being offered by the employer unless prior agreement is granted by SIHO. Only employees who waive coverage and provide proof of creditable coverage in regard to eligibility will be excluded from the number of eligible employees in order to verify that participation is met. For all groups, participation less than 50% of the total full-time employees, including those who waive coverage, will not be considered eligible. Employees who are full-time, working a minimum of 30 hours per week in the regular business of the employer, are eligible for coverage. The employer must contribute a minimum of 50% of the employee only monthly premium. If the employer contributes 100% of the employee only monthly premium then 100% of the eligible employees must enroll and employees will not be able to waive coverage. An eligible dependent is a spouse or a child who is under the age of 26 and is a natural born or legally adopted son, daughter or stepchild. Initial Enrollees Coverage will take effect on the participating employer group s effective date. Following the initial open enrollment period, an annual open enrollment shall be held each year starting 45 days prior to the anniversary date of the policy. Anyone wishing to join the plan at a time other than the effective date of the group is considered a late enrollee and must meet the criteria below to be covered under the employer s health plan. Anyone choosing not to enroll during the initial enrollment period must wait until the next open enrollment period to do so. Coverage will take effect on the participating employer s anniversary date. Late Enrollees A member may be added as a late enrollee effective on a date other than the anniversary date if the member experiences a qualifying event. Qualifying events include (but are not limited to) marriage, birth, adoption or spousal loss of coverage. 14

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16 These benefits are fully compliant with the Affordable Care Act (PPACA). Wellness Exam: Men - One per year Women - One per year with family physician, one per year with OB/GYN, if needed AGE 1 Vaccine > Birth month Diphtheria, Tetanus, Pertussis Human Papillomavirus Meningococcal Influenza Childhood Immunizations months months months months months Note: Preferred age for vaccine is indicated where specific vaccine is listed in colored box. *Varicella expanded for 2nd dose to age months months years years years years years DTap DTap DTap DTap DTap TDap HPV 3 Doses MCV Influenza (yearly) Pneumococcal PCV PCV PCV PCV PPSV Hepatitis A Hep A 2 Doses Hep A Series Hepatitis B Hep B Hep B Hep B Hep B Series Inactivated Poliovirus IPV IPV IPV IPV Measles, Mumps, Rubella MMR MMR Varicella* Varicella Varicella Rotavirus RV RV RV Haemophilus Influenzae Type B HIB HIB HIB HIB Services for Children Services for Pregnant Women Gonorrhea preventative medication for eyes Hearing Screening Hemoglobinopathies (sickle cell) Congenital Hypothyroidism Phenylketonuria (PKU) Fluoride Supplement Iron Screening and Supplementation Newborns Children without fluoride in water source All Ages Developmental/Behavioral Assessment/Autism Hematocrit or Hemoglobin Screening Lead Screening All Ages All Ages For children at risk of exposure HIV Screening Age 12 and above Dyslipidemia Screening All Ages Aspirin HIV Bacteriuria Hepatitis B Iron Deficiency Anemia Gestational Diabetes Screening (between 24 & 28 weeks) Rh Incompatibility Syphilis Screening Breast Feeding Interventions* Nicotine* For Those At Risk Screening Lab test Lab test Lab test Lab test Lab test Lab test Counseling, Support & Supplies Counseling Visual Acuity Up to Age 5 Height, Weight and Body Mass Index measurements All Ages Folic Acid Women capable of becoming pregnant Oral Dental Screening During PHB visit Medical History All Children throughout development Services for All Women Domestic Violence Annually Screening & Counseling Urinalysis All Ages Contraceptive Methods* Covered unless religious exemption applies 16

17 Adult Immunizations Adult Procedures/Services Adult Labs Tdap once, then Tb Tetanus, Diphtheria, booster every 10 years Pertussis after age 18 Human Papillomavirus To age 26 Meningococcal To age 65 Influenza Every year Pneumococcal Ages 19 to 65 Hepatitis A 2 to 3 doses to age 65 Hepatitis B 3 doses to age 65 Shingles Once after age 50 Once after age 19 (up Measles, Mumps and to two vaccinations per Rubella* lifetime) Tamoxifen/Raloxifene At risk Women Varicella 2 doses to age 65 Bone Density Scan Mammogram Mammogram BRCA (letter of medical necessity required) Sigmoidoscopy Colonoscopy Abdominal Aortic Aneurysm Screening Aspirin for Men Aspirin for Women Lung Cancer Screening Every 2 years age 60 or older Baseline - women, once between ages Yearly for women over 40 Women genetically at high risk of breast cancer Every 3 years after age 50 Every 10 years after age 50 For men who have smoked - one time between ages At risk Ages At risk Ages At risk Ages Lipid Panel Yearly Total Serum Cholesterol Yearly PSA Yearly Men over 50 Pap Smear/Thin Prep Pap Test Yearly Fecal Occult Testing Yearly after age 50 FBS (Fasting Blood Sugar) Yearly Hgb A1C Yearly HIV Testing Yearly after age 15 Human Papillomavirus DNA Testing Yearly Syphilis Screening At risk Chlamydia Infection Screening Yearly - All ages Gonorrhea Screening Yearly - All ages Hepatitis B & Hepatitis C Screenings Yearly Urinalysis Yearly Statin Preventative Medication At risk Ages Vitamin D Deficiency Screening Yearly after age 40 Obesity Healthy Diet It is recommended that a preventive health visit include screenings and counseling for: Developmental/ Behavioral Assessment/Autism Tobacco Blood Pressure Skin Cancer Prevention Breast Cancer Chemoprevention for Women at High Risk Fall Depression Alcohol Sexually Transmitted Infections Risk The SIHO Preventive Health Benefit Guidelines are developed and periodically reviewed by SIHO s Quality Management Committee, a group of local physicians and health care providers. The QMC reviews routine care services from the American Academy of Family Practice Standards, American College of OB/GYN Standards, Center for Disease Control Recommendations, American Cancer Society Recommendations, American Academy of Pediatric Standards and U.S. Preventive Services Task Force Recommendations. These recommendations were combined with input from local physicians and the standard Preventive Health Benefit was developed. These standards and recommendations are reviewed every one to two years, and the benefits are updated as needed. Please note that your physician may recommend additional tests or screenings not included in this benefit. If you receive routine screenings that are not listed in this brochure you may have financial responsibility for those charges. A screening procedure performed when there is a family history or personal history of a condition (and which does not fall within the listed age/ frequency criteria of the Preventive Health Benefit) will be covered under the major medical benefit. *Please contact SIHO Member Services at for specific coverage information. Updated

18 If you cannot find your Physician of choice in Encircle/Encore s, select Landmark Combined from the SIHO Provider Directory. Type in the name of the Physician For TIER 1 PHYSICIANS in the and/or address SIHO select SIHO information where from the drop indicated. down menu. You can also search by Provider Type, Primary Care, Specialty Care or Mid-Level Specialty For a listing of TIER 2 FACILITIES, select Landmark Combined Tier 2 from the drop down Menu. Type in the name of the Facility and/or address information where indicated. You can also search by Provider Type: Facilities If you have questions, contact Member Services at

19 To find medical providers in your network, click on the Landmark Combined link. Click on Member then select Provider Directory. Click on the Encircle/Encore link. You will be directed to Select Provider Search. Select the Encircle/Encore Health : this is a listing of Tier 1 Physicians and Facilities. Tier 1 Providers offer the best benefit. If you are searching for a specific provider and do not see them listed, see following page for instructions. 19

20 SIHO s Provider plays a key role in SIHO s health plans. SIHO has one of the most comprehensive networks of hospitals and physicians. As a result, our clients benefit from the most competitive discounts in the marketplace. SIHO s proprietary network consists of more than 30,000 health care providers and hospital facilities. SIHO also has access to physicians and hospital networks throughout the United States for employees outside our primary coverage area and for groups with multiple locations. What does this mean to you? If you are enrolled in the Medical plan on Month day, year, your benefits will be based on the network in which your provider participates. Instead of the traditional 2-Tier plan (In and Out of ), your plan will have three tiers of benefits. Providers include all currently contracted SIHO and Encore physicians and Encircle network facilities Benefits provided by Tier 1 providers will be subject to the lowest, lowest out of pocket Providers include all currently contracted SIHO and Encore facilities not in the Encircle network Benefits provided by Tier 2 providers will be subject to slightly higher deductibles, slightly higher out of pocket maximums, and slightly lower coinsurance Providers who are not contracted with either SIHO, Encircle, or Encore will be in this category (Out of ) Benefits provided by these providers will be subject to the highest deductibles, out of pocket maximums, and lowest coinsurance General Information Benefits reflect contracted rates and balance billing may apply Deductibles and out-of-pocket maximums cross apply between Tier 1 and Tier 2 providers. You may look for providers at and select the provider search option. 20

21 2018 PLAN OFFERINGS 21

22 Southeastern Indiana Health Organization, Inc. Landmark Combined PC Choice 2018 Large Group Plan Designs Prime Care Choice $500 Price Care Choice $1000 Plan Code LGS LGT Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- Annual Single Deductible $500 $1,000 $2,000 $1,000 $2,000 $3,000 Annual Family Deductible $1,000 $2,000 $4,000 $2,000 $4,000 $6,000 Annual OOP Max - Single (incl Deductible) $4,000 $5,500 $8,000 $5,000 $6,500 $9,000 Annual OOP Max - Family (incl Deductible) $8,000 $11,000 $16,000 $10,000 $13,000 $18,000 PCP Office Visit $20 $20 Ded, 50% $25 $25 Ded, 50% Specialist Office Visit $30 $30 Ded, 50% $40 $40 Ded, 50% Preventive Care 0% 0% Not Covered 0% 0% Not Covered Inpatient Hospital Services Outpatient Hospital Services Professional Services (In & Out) Emergency Room $150 $150 $150 $150 $150 $150 Urgent Care Facility $30 $30 Ded, 50% $40 $40 Ded, 50% Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% PT/OT/Speech Therapy (20 visit annual max each) Chiropractic Services (15 visit annual max) $30 $30 Ded, 50% $40 $40 Ded, 50% DME/Orthotics & Prosthetic Devices Inpatient Behavioral Health Outpatient Behavioral Health (4 free visits) $20 $20 Ded, 50% $25 $25 Ded, 50% Skilled Nursing Facility/LTACH (45 day max) Acute Inpatient Rehabilitation (45 day max) Home Health* (60 day annual max) Hospice Pharmacy: Generic Drug $10 $10 Ded, 50% $10 $10 Ded, 50% Brand Name Formulary $30 $30 Ded, 50% $30 $30 Ded, 50% Brand Name Non-Formulary $45 $45 Ded, 50% $45 $45 Ded, 50% Specialty Drugs** ($500 maximum) Ded, 25% Ded, 25% Not Covered Ded, 25% Ded, 25% Not Covered Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by 22

23 Prime Care Choice $1500 Prime Care Choice $2500 LGU LGV Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- $1,500 $2,500 $4,000 $2,500 $3,500 $5,000 $3,000 $5,000 $8,000 $5,000 $7,000 $10,000 $6,000 $7,350 $10,000 $7,350 $7,350 $11,000 $12,000 $14,700 $20,000 $14,700 $14,700 $22,000 $25 $25 Ded, 50% $25 $25 Ded, 50% $40 $40 Ded, 50% $40 $40 Ded, 50% 0% 0% Not Covered 0% 0% Not Covered $150 $150 $150 $150 $150 $150 $40 $40 Ded, 50% $40 $40 Ded, 50% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% $40 $40 Ded, 50% $40 $40 Ded, 50% $25 $25 Ded, 50% $25 $25 Ded, 50% $10 $10 Ded, 50% $10 $10 Ded, 50% $40 $40 Ded, 50% $40 $40 Ded, 50% $60 $60 Ded, 50% $60 $60 Ded, 50% Ded, 25% Ded, 25% Not Covered Ded, 25% Ded, 25% Not Covered 2.5x 2.5x N/A 2.5x 2.5x N/A 23

24 Prime Care Choice $3500 Prime Care Choice $5000 Plan Code LGY LGZ Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- Annual Single Deductible $3,500 $4,500 $7,000 $5,000 $6,000 $7,500 Annual Family Deductible $7,000 $9,000 $14,000 $10,000 $12,000 $15,000 Annual OOP Max - Single (incl Deductible) $7,350 $7,350 $14,000 $7,350 $7,350 $16,000 Annual OOP Max - Family (incl Deductible) $14,700 $14,700 $28,000 $14,700 $14,700 $32,000 PCP Office Visit $30 $30 Ded, 50% $30 $30 Ded, 50% Specialist Office Visit $50 $50 Ded, 50% $50 $50 Ded, 50% Preventive Care 0% 0% Not Covered 0% 0% Not Covered Inpatient Hospital Services Outpatient Hospital Services Professional Services (In & Out) Emergency Room $200 $200 $200 $200 $200 $200 Urgent Care Facility $50 $50 Ded, 50% $50 $50 Ded, 50% Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum) $50 $50 Ded, 50% $50 $50 Ded, 50% DME/Orthotics & Prosthetic Devices Inpatient Behavioral Health Outpatient Behavioral Health (4 free visits) $30 $30 Ded, 50% $30 $30 Ded, 50% Skilled Nursing Facility/LTACH (45 day maximum) Acute Inpatient Rehabilitation (45 day maximum) Home Health (60 visit annual maximum) Hospice Pharmacy: Generic Drug $15 $15 Ded, 50% $15 $15 Ded, 50% Brand Name Formulary $45 $45 Ded, 50% $45 $45 Ded, 50% Brand Name Non-Formulary $70 $70 Ded, 50% $70 $70 Ded, 50% Specialty Drugs** Ded, 25% Ded, 25% Not Covered Ded, 25% Ded, 25% Not Covered Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $

25 HSA Plan $ % HSA Plan $ % Plan Code L8S L8T Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- Annual Single Deductible $1,350 $1,500 $2,200 $2,700 $3,500 $4,000 Annual Family Deductible $2,700 $3,000 $4,400 $5,400 $7,000 $8,000 Annual OOP Max - Single (incl Deductible) $5,000 $5,500 $9,000 $6,000 $6,650 $11,000 Annual OOP Max - Family (incl Deductible) $10,000 $11,000 $18,000 $12,000 $13,300 $22,000 Family Deductible / OOP Max Non-Embedded/Embedded Embedded PCP Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Specialist Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Preventive Care 0% 0% Not Covered 0% 0% Not Covered Inpatient Hospital Services Outpatient Hospital Services Professional Services (In & Out) Emergency Room Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Urgent Care Facility Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum) Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% DME/Orthotics & Prosthetic Devices Inpatient Behavioral Health Outpatient Behavioral Health Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Skilled Nursing Facility/LTACH (45 day maximum) Acute Inpatient Rehabilitation (45 day maximum) Home Health (60 visit annual maximum) Hospice Pharmacy: Generic Drug Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Brand Name Formulary Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Brand Name Non-Formulary Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Specialty Drugs** Ded, 20% Ded, 20% Not Covered Ded, 20% Ded, 20% Not Covered 25

26 HSA Plan $2500 0% HSA Plan $ % Plan Code L8U L8V Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- Annual Single Deductible $2,700 $4,000 $5,000 $3,500 $4,500 $7,000 Annual Family Deductible $5,400 $8,000 $10,000 $7,000 $9,000 $14,000 Annual OOP Max - Single (incl Deductible) Annual OOP Max - Family (incl Deductible) $2,700 $4,000 $13,000 $6,000 $6,650 $13,000 $5,400 $8,000 $26,000 $12,000 $13,300 $26,000 Family Deductible / OOP Max Embedded Embedded PCP Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Specialist Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Preventive Care 0% 0% Not Covered 0% 0% Not Covered Inpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Outpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Professional Services (In & Out) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Emergency Room Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20% Urgent Care Facility Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ambulance Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20% PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum) DME/Orthotics & Prosthetic Devices Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Inpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Outpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Skilled Nursing Facility/LTACH (45 day maximum) Acute Inpatient Rehabilitation (45 day maximum) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Home Health (60 day maximum) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Hospice Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Pharmacy: Generic Drug Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Brand Name Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Brand Name Non-Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Specialty Drugs** Ded, 0% Ded, 0% Not Covered Ded, 20% Ded, 20% Not Covered ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $

27 HSA Plan $ % HSA Plan $5000 0% Plan Code L8Y L8Z Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- Annual Single Deductible $5,000 $6,500 $10,000 $5,000 $6,650 $10,000 Annual Family Deductible $10,000 $13,000 $20,000 $10,000 $13,300 $20,000 Annual OOP Max - Single (incl Deductible) Annual OOP Max - Family (incl Deductible) $6,650 $6,650 $16,000 $5,000 $6,650 $16,000 $13,300 $13,300 $32,000 $10,000 $13,300 $32,000 Family Deductible / OOP Max Embedded Embedded PCP Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Specialist Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Preventive Care 0% 0% Not Covered 0% 0% Not Covered Inpatient Hospital Services Outpatient Hospital Services Professional Services (In & Out) Emergency Room Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Urgent Care Facility Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum) DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Inpatient Behavioral Health Outpatient Behavioral Health Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Skilled Nursing Facility/LTACH (45 day maximum) Acute Inpatient Rehabilitation (45 day maximum) Home Health (60 day maximum) Hospice Pharmacy: Generic Drug Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Brand Name Formulary Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Brand Name Non-Formulary Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Specialty Drugs** Ded, 20% Ded, 20% Not Covered Ded, 0% Ded, 0% Not Covered 27

28 HRA Plan $1000/20% HRA Plan $1500/20% Plan Code L71 L72 Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- Annual Single Deductible Annual Family Deductible Annual OOP Max - Single (incl Deductible) Annual OOP Max - Family (incl Deductible) Family Deductible / OOP Max PCP Office Visit Specialist Office Visit Preventive Care Inpatient Hospital Services Outpatient Hospital Services Professional Services (In & Out) Emergency Room Urgent Care Facility Ambulance PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum) DME/Orthotics & Prosthetic Devices Inpatient Behavioral Health Outpatient Behavioral Health Skilled Nursing Facility/LTACH (45 day maximum) Acute Inpatient Rehabilitation (45 day maximum) Home Health (60 day maximum) Hospice $1,000 $1,500 $2,000 $1,500 $2,000 $3,000 $2,000 $3,000 $4,000 $3,000 $4,000 $6,000 $5,000 $7,000 $9,000 $6,000 $7,350 $11,000 $10,000 $14,000 $18,000 $12,000 $14,700 $22,000 Embedded Embedded Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% 0% 0% Not Covered 0% 0% Not Covered Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Pharmacy: Generic Drug $10 $10 Ded, 50% $10 $10 Ded, 50% Brand Name Formulary $30 $30 Ded, 50% $30 $30 Ded, 50% Brand Name Non-Formulary $45 $45 Ded, 50% $45 $45 Ded, 50% Specialty Drugs** Ded, 25% Ded, 25% Not Covered Ded, 25% Ded, 25% Not Covered Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $

29 HRA Plan $2000/20% HRA Plan $2000/0% L73 L74 Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- $2,000 $3,000 $4,000 $2,000 $3,500 $4,000 $4,000 $6,000 $8,000 $4,000 $7,000 $8,000 $6,000 $7,350 $12,000 $3,000 $4,500 $12,000 $12,000 $14,700 $24,000 $6,000 $9,000 $24,000 Embedded Embedded Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% 0% 0% Not Covered 0% 0% Not Covered Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% $10 $10 Ded, 50% $10 $10 Ded, 50% $40 $40 Ded, 50% $40 $40 Ded, 50% $60 $60 Ded, 50% $60 $60 Ded, 50% Ded, 25% Ded, 25% Not Covered Ded, 25% Ded, 25% Not Covered 2.5x 2.5x N/A 2.5x 2.5x N/A 29

30 HRA Plan $2500/20% HRA Plan $2500/0% Plan Code L75 L76 Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- Annual Single Deductible $2,500 $3,500 $5,000 $2,500 $4,000 $5,000 Annual Family Deductible $5,000 $7,000 $10,000 $5,000 $8,000 $10,000 Annual OOP Max - Single (incl Deductible) Annual OOP Max - Family (incl Deductible) $7,000 $7,350 $13,000 $3,500 $5,000 $13,000 $14,000 $14,700 $26,000 $7,000 $10,000 $26,000 Family Deductible / OOP Max Embedded Embedded PCP Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Specialist Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Preventive Care 0% 0% Not Covered 0% 0% Not Covered Inpatient Hospital Services Outpatient Hospital Services Professional Services (In & Out) Emergency Room Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Urgent Care Facility Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum ) DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Inpatient Behavioral Health Outpatient Behavioral Health Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Skilled Nursing Facility/LTACH (45 day maximum) Acute Inpatient Rehabilitation (45 day maximum) Home Health (60 day maximum) Hospice Pharmacy Generic Drug $10 $10 Ded, 50% $10 $10 Ded, 50% Brand Name Formulary $40 $40 Ded, 50% $40 $40 Ded, 50% Brand Name Non-Formulary $60 $60 Ded, 50% $60 $60 Ded, 50% Specialty Drugs** Ded, 25% Ded, 25% Not Covered Ded, 25% Ded, 25% Not Covered Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $

31 HRA Plan $5000/20% HRA Plan $5000/0% L77 L78 Tier 1 Tier 2 Tier 3 Out-of- Tier 1 Tier 2 Tier 3 Out-of- $5,000 $6,500 $10,000 $5,000 $6,600 $10,000 $10,000 $13,000 $20,000 $10,000 $13,200 $20,000 $7,350 $7,350 $16,000 $6,000 $7,350 $16,000 $14,700 $14,700 $32,000 $12,000 $14,700 $32,000 Embedded Embedded Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% 0% 0% Not Covered 0% 0% Not Covered Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% $15 $15 Ded, 50% $15 $15 Ded, 50% $45 $45 Ded, 50% $45 $45 Ded, 50% $70 $70 Ded, 50% $70 $70 Ded, 50% Ded, 25% Ded, 25% Not Covered Ded, 25% Ded, 25% Not Covered 2.5x 2.5x N/A 2.5x 2.5x N/A 31

32 Click on Member then select Provider Directory. Click on SIHO Landmark In order to find a provider, you may need to select a network you are interested in from a drop menu. Type in the name of the Provider and address information where indicated. You can also search by Specialty. 32

33 SIHO s Provider plays a key role in SIHO s health plans. SIHO has one of the most comprehensive networks of hospitals and physicians. As a result, our clients benefit from the most competitive discounts in the marketplace. SIHO s proprietary network consists of more than 30,000 health care providers and hospital facilities. SIHO also has access to physicians and hospital networks throughout the United States for employees outside our primary coverage area and for groups with multiple locations. What does this mean to you? If you are enrolled in the Medical plan on Month day, year, your benefits will be based on the network in which your provider participates. In the 2-tier or level Landmark network option, providers are either in-network or out-of-network. Providers include SIHO and Encore physicians and facilities Benefits provided by these providers will be subject to the lowest deductible, lowest out of pocket maximum, and the highest coinsurance Providers who are not contracted with either SIHO or Encore will be in this category Benefits provided by these providers will be subject to the highest deductibles, out of pocket maximums, and lowest coinsurance 33

34 PC Choice $500 PC Choice $1000 PC Choice $1500 Plan Code 8BP 8BQ 8BR Annual Single Deductible $500 $1,000 $1,500 Annual Family Deductible $1,000 $2,000 $3,000 Annual OOP Max - Single (incl Deductible) Annual OOP Max - Family (incl Deductible) $4,000 $5,000 $6,000 $8,000 $10,000 $12,000 PCP Office Visit $20 $25 $25 Specialist Office Visit $30 $40 $40 Preventive Care 0% 0% 0% Inpatient Hospital Services Ded, 20% Ded, 20% Ded, 20% Outpatient Hospital Services Ded, 20% Ded, 20% Ded, 20% Professional Services (In & Out) Ded, 20% Ded, 20% Ded, 20% Emergency Room $150 $150 $150 Urgent Care Facility $30 $40 $40 Ambulance Ded, 20% Ded, 20% Ded, 20% PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum) DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 20% Ded, 20% $30 $40 $40 Ded, 20% Ded, 20% Ded, 20% Inpatient Behavioral Health Ded, 20% Ded, 20% Ded, 20% Outpatient Behavioral Health (4 free visits) Skilled Nursing Facility/LTACH (45 day annual maximum) Acute Inpatient Rehabilitation (45 day annual maximum) Home Health (60 day annual maximum) $20 $25 $25 Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Hospice Ded, 20% Ded, 20% Ded, 20% Out of : Annual Single Deductible $1,000 $2,000 $3,000 Annual Family Deductible $2,000 $4,000 $6,000 Coinsurance for All Services* 50% 50% 50% Annual OOP Max - Single $7,000 $9,000 $11,000 Annual OOP Max - Family $14,000 $18,000 $22,000 Pharmacy: Generic Drug $10 $10 $10 Brand Name Formulary $30 $30 $40 Brand Name Non-Formulary $45 $45 $60 Specialty Drugs** Ded, 25% Ded, 25% Ded, 25% Mail Order 2.5x 2.5x 2.5x * OON Coinsurance applies to all services, except for Emergency Room services, which are legally required to be that of INN. ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $

35 PC Choice $2500 PC Choice $3500 PC Choice $5000 8BS 8BT 8BU $2,500 $3,500 $5,000 $5,000 $7,000 $10,000 $7,350 $7,350 $7,350 $14,700 $14,700 $14,700 $25 $30 $30 $40 $50 $50 0% 0% 0% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% $150 $200 $200 $40 $50 $50 Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% $40 $50 $50 Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% $25 $30 $30 Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% $5,000 $7,000 $8,000 $10,000 $14,000 $16,000 50% 50% 50% $13,000 $16,000 $19,000 $26,000 $32,000 $38,000 $10 $15 $15 $40 $45 $45 $60 $70 $70 Ded, 25% Ded, 25% Ded, 25% 2.5x 2.5x 2.5x 35

36 HSA Plan 1 HSA Plan 2 HSA Plan 3 HSA Plan 4 HSA Plan 5 HSA Plan 6 Plan Code 8YH 8YJ 8YK 8YL 8YM 8YN Annual Single Deductible $1,350 $1,500 $1,500 $2,000 $2,000 $2,700 Annual Family Deductible $2,700 $3,000 $3,000 $4,000 $4,000 $5,400 Annual OOP Max - Single (incl Deductible) $5,000 $1,500 $6,000 $2,000 $6,000 $2,700 Annual OOP Max - Family (incl Deductible) $10,000 $3,000 $12,000 $4,000 $12,000 $5,400 Family Deductible / OOP Max Non-Embedded/ Embedded Non-Embedded/ Embedded Non-Embedded/ Embedded Non-Embedded/ Embedded Non-Embedded/ Embedded Embedded PCP Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Specialist Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Preventive Care 0% 0% 0% 0% 0% 0% Inpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Outpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Professional Services (In & Out) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Emergency Room Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Urgent Care Facility Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ambulance Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Inpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Outpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Skilled Nursing Facility/LTACH (45 day annual maximum) Acute Inpatient Rehabilitation (45 day annual maximum) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Home Health (60 day annual maximum) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Hospice Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Out of : Annual Single Deductible $2,500 $3,000 $3,000 $4,000 $4,000 $5,000 Annual Family Deductible $5,000 $6,000 $6,000 $8,000 $8,000 $10,000 Coinsurance for All Services* 50% 50% 50% 50% 50% 50% Annual OOP Max - Single $10,000 $11,000 $11,000 $12,000 $12,000 $13,000 Annual OOP Max - Family $20,000 $22,000 $22,000 $24,000 $24,000 $26,000 Pharmacy: Generic Drug Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Brand Name Formulary Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Brand Name Non-Formulary Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Specialty Drugs** Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% * OON Coinsurance applies to all services, except for Emergency Room services, which are legally required to be that of INN. ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $

37 HSA Plan 7 HSA Plan 8 HSA Plan 9 HSA Plan 10 HSA Plan 11 Plan Code 8YP 8YQ 8YR 8YS 8YT Annual Single Deductible $2,,700 $3,500 $3,500 $5,000 $5,000 Annual Family Deductible $5,400 $7,000 $7,000 $10,000 $10,000 Annual OOP Max - Single (incl Deductible) $6,000 $3,500 $6,000 $5,000 $6,650 Annual OOP Max - Family (incl Deductible) $12,000 $7,000 $12,000 $10,000 $13,300 Family Deductible / OOP Max Embedded Embedded Embedded Embedded Embedded PCP Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Specialist Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Preventive Care 0% 0% 0% 0% 0% Inpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Outpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Professional Services (In & Out) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Emergency Room Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Urgent Care Facility Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ambulance Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% PT/OT/Speech Therapy (20 visit annual maximum each) Chiropractic Services (15 visit annual maximum ) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Inpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Outpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Skilled Nursing Facility/LTACH (45 day annual maximum) Acute Inpatient Rehabilitation (45 day annual maximum) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Home Health (60 day annual maximum) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Hospice Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Out of : Annual Single Deductible $5,000 $7,000 $7,000 $10,000 $10,000 Annual Family Deductible $10,000 $14,000 $14,000 $20,000 $20,000 Coinsurance for All Services* 50% 50% 50% 50% 50% Annual OOP Max - Single $13,000 $15,000 $15,000 $19,000 $19,000 Annual OOP Max - Family $26,000 $30,000 $30,000 $38,000 $38,000 Pharmacy: Generic Drug Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Brand Name Formulary Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Brand Name Non-Formulary Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Specialty Drugs** Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% 37