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1 204 Benefits Summary - RETIREMENT VISION PAID TIME OFF MEDICAL DENTAL LIFE DISABILITY RETIREMENT VISION PAID TIME OFF MEDICAL DENTAL LIFE DISABILITY RETIREMENT VISION PAID TIME OFF MEDICAL DENTAL LIFE DISABILITY RETIREMENT VISION PAID TIME OFF MEDICAL DENTAL LIFE DISABILITY RETIREMENT VISION PAID TIME OFF MEDICAL DENTAL LIFE DISABILITY RETIREMENT

2 MEDICAL COVERAGE The medical coverage you will have as part of the Southern Regional Health System family provides financial protection against the expense of an illness or injury and offers preventive benefits to help you stay healthy. Coverage is available for you and your eligible dependents. You will be able to choose from three different plans. Please review the chart below to see how the plans compare. Our plan premiums are withheld on a pretax basis, which is a tax advantage for you. All plans are self-insured ERISA plans administered by Coventry Health Care of Georgia, Inc. In-network services are medically necessary items or services provided to a member by an SRHS or Coventry participating provider. Out-of-network services are available under the Premier Plus Plan and Value Plan ONLY, except in emergency situations. For the three plans, the deductible must be met before coinsurance is paid. If you have questions about your benefits, please contact Customer Service at (866) , Monday - Friday 7:00 a.m. - 6:00 p. m. Member pays amounts listed below. SUMMARY Preventive Health Services (Based on US Preventive Services Task Force Guidelines) PREMIER HRA PLAN PREMIER PLUS HRA PLAN SRHS In Network Coventry In Network SRHS In Network Coventry In Network Out of Network SRHS In Network VALUE PLAN Coventry In Network Out of Network Routine physical exams including well baby, well child, and adult exams according to schedule. A female member may self-refer to an OB/GYN for annual well woman exam. OB/GYN specific services as defined in the plan document. Routine Physical Exams: Primary Care Physician Office Visit Deductible 2, 3, 6, 8 Deductible 2, 3, 6, 8 Physician Services Inpatient hospital, extended care, rehab and skilled nursing facility services by physicians, including the services of a surgeon, assistant surgeon, anesthesiologists, pathologists and radiologists. after Deductible $550 copay $550 copay Deductible $500 copay Deductible Office visits by the primary care physician or specialist physician. Primary Care Physician Office Visit $ 5 per visit 4 Deductible Deductible Laboratory, -ray, diagnostics provided in Physicians Office Deductible Deductible Self injectable medications 0% Coinsurance 0% Coinsurance 0% Coinsurance 0% Coinsurance Deductible then Deductible then 0% Coinsurance 0% Coinsurance Health education/health promotion services if prescribed by a physician and if the education program is offered by Southern Regional Health System and covered by the plan. Primary Care Physician Office Visit or charge, or charge, or charge, or charge, or charge, or charge, or charge, or charge, or charge, $50 per visit or charge, or charge, $50 per visit or charge, Routine vision exams (Limited to one vision examination every 2 months with a participating ophthalmologist.) $45 7 $ $45 7 $ $ $ 7 Pregnancy and Maternity Care Prenatal & postnatal physician office visits & delivery (requires precertification in the first trimester). All necessary inpatient hospital services for normal delivery, professional fees, cesarean section, and complication of pregnancy. Midwife services must be performed under the direct supervision of a participating obstetrician. $45 Physician plus Deductible (includes all hospital services) $65 Physician plus Deductible & $ copay (includes all hospital services) $45 Physician plus Deductible 550 (includes all hospital services) $65 Physician plus Deductible & $ 550 copay (includes all hospital services) Deductible,6 (includes all hospital services) $50 Physician then Deductible & $ 250 copay (includes all hospital services) $70 Physician then Deductible & $ 600 copay (includes all hospital services) Deductible,6 (includes all hospital services) Allergy Testing and Treatment Office visits, serum and testing Primary Care Office $ 5 per visit 4 Deductible,6 Deductible,6 Allergy Injections only 6 6

3 Hospital Services Inpatient services including semi-private room and board, operating room, intensive care units, general nursing care, drugs, medications, oxygen, blood and blood plasma $550 $550 0 Outpatient hospital services or surgery including necessary supplies $400 $400 $250 MRI, CATS, PETS, -Ray, Mammography (other than routine) At Facility $400 $400 $250 At Physician office $45 $75 $75 $ 00 $ 50 Specialty Facility Services Inpatient skilled nursing facility services, extended care facility services, rehab facility services and other necessary services in lieu of acute hospital care. Custodial care is not covered. $450 (max 60 Days/yr) $450 (max 60 Days/yr) Deductible,6 $400 (max 60 Days/yr) Deductible,6 Hospice Inpatient $450 $450 Deductible,6 $400 Deductible,6 Outpatient services and surgery including necessary supplies $400 $400 Deductible,6 $250 Deductible,6 MRI, CATS, PETS, -Ray, Mammography (other than routine) $400 $400 Deductible,6 $250 Deductible,6 Mental Health and Chemical Dependency Specialist physician office visit (outpatient) 7 $ 45 per visit 7 7 $ 45 per visit 7 Deductible 6, Deductible 6, 7 Inpatient care $ 450 $ 450 $ 400 Inpatient Specialist residential treatment $ 450 $ 450 $ 400 Outpatient evening program / Partial Hospital Program $ 45 per visit $ 45 per visit Home Health Care Home health care services including home visits by a nurse, physical therapist, respiratory therapist, occupational therapist or hospice care in the home by home health care providers in lieu of acute hospital care., 6, 6, 6, 6 Hospice Outpatient office visit Home visits by Plan physicians Home IV therapy (after initial setup) Short-term Rehabilitation Therapy (Outpatient) Rehabilitation therapy by a physical, occupational, respiratory, or speech therapist for a single illness or injury. Coverage is limited to 20 medically necessary office visits per condition per benefit year. per visit $ 75 per visit, 6 per visit $75 per visit, 6 $40,6 $70,6 Reconstructive Surgery Inpatient or outpatient surgery to repair or alleviate bodily damage caused by illness or injury that occurred to a member while covered by this plan, within 2 months of the injury or illness and reconstructive surgery incidental to a mastectomy. after Deductible, 6 after Deductible, 6 Ded. plus $550, 6 Ded. plus $400, 6 $550 $ 4 00 Inpatient and Outpatient Deductible, 6 0 $ 00 4 Inpatient and Outpatient Deductible, 6

4 Treatment of the Teeth, Gums, Jaw Joints, or Jaw Bones Hospital and professional services for the treatment of injuries to sound natural teeth incurred while you are covered under your employees healthcare plan. For oral surgery for infection, disease, and injuries of the jaw joints or jaw bones, including adjacent tissues, TMJ as specifically stated. Impacted wisdom teeth removal is not a covered benefit under the plans. $75 $00 $75 $00 Inpatient and Deductible, 6 $75 $00 Inpatient and Deductible, 6 Emergency Services Emergency room services when medically necessary (waived if admitted within 24 hours) Urgent care facilities when medically necessary $50 per visit $50 per visit $50 per visit $50 per visit $00 $75 per visit $75 per visit $75 per visit Convenience care Ambulance for emergency services $50 per occurence $50 per occurence $50 per occurence $50 per occurence $50 per occurence $00 per occurrence $00 per occurrence Miscellaneous Durable medical supplies,prosthesis and orthosis (as defined) 25% Coinsurance 25% Coinsurance 25% Coinsurance 25% Coinsurance 50% Coinsurance 50% Coinsurance (Coinsurance does not apply to out-of-pocket maximum) Deductible, 6 Deductible, 6 6, 7 6, 7 6, 7 6, 7 Chiropractic Care not to exceed 20 visits per plan year. (must use an ActivHealthCare Network of providers). Chiropractic auto liability claims are not covered. Family planning counseling and medical devices Primary Care Office Birth control prescription drugs (subject to plan limitation and exclusions) Bariatric Surgery Deductible, 6 per visit $2,000 copay $2,000 $2,000 per visit per visit Deductible, 6 Out-of-Pocket SRHS Funded Health Reimbursement Account *Must participate in Wellness Program to earn. - Annual $500 single $750 single + $,000 family $500 single $750 single + $,000 family Does not apply Out-of-pocket expenses are the co-insurance and/or deductible amount you are responsible for paying. Annual deductible $,000 single with a $3,000 / plan year $,500 single with a $4,500 / plan year $3,000 single with a $9000 / plan year Single: $,500 Single +: $2,500 Family: $3,500 Single: $3,000 Single +: $5,000 Family: $7,000 Annual out-of-pocket maximums- There are annual out-of-pocket maximums after which you no longer have to pay for specific services. Pharmacy copays are not included in the annual out-of-pocket maximums. (out-of-pocket maximums exclude pharmacy copayment and payment for non-covered services.) $4,000 single with a $2,000 / plan year $4,000 single with a $2,000 / plan year $8,000 single with a $24,000 / plan year $6,250 single with a $2,500 / plan year Single: $2,500 Single +: $8,750 Family: $25,000 Lifetime Benefits Benefits maximum for all services. No lifetime maximum No lifetime maximum No lifetime maximum Prescription Drugs Administered by Express Scripts Outpatient Prescription Drugs Copays If a member requests a brand name drug when a generic substitute is available (even if the prescription is written Dispense as Written ) the member will be responsible for the name brand copay plus the cost difference between the brand drug and the available generic substitute. 4 Member must use participating pharmacies on all three plans. Note: There are quantity limits on some medications. Self Administered Injectibles require prior authorization. Pharmacy copays do not apply to the out-of-pocket maximum. $2 Tier $75 Tier 3 0% Co-Insurance 0% Co-Insurance 0% Co-Insurance 0% Co-Insurance $00 SAI Co-pay $00 SAI Co-pay $30 Tier $00 Tier 2 $85 Tier 3 $2 Tier $75 Tier 3 $30 Tier $00 Tier 2 $85 Tier 3 $2 Tier $75 Tier 3 $30 Tier $00 Tier 2 $85 Tier 3 $2 Tier $75 Tier 3 $30 Tier $00 Tier 2 $85 Tier 3 Ded doesn't apply to Tier Ded doesn't apply to Tier $2 Tier $75 Tier 3 $30 Tier $00 Tier 2 $85 Tier 3 $2 Tier $75 Tier 3 $30 Tier $00 Tier 2 $85 Tier 3. Precertification of service may be required in order for benefits to be payable. 2. Specialty physician care may require prior authorization. 3. Includes office visit, test, and lab work. 4. No reimbursement is available if prescription drugs are purchased at a nonparticipating pharmacy, except in the event of an emergency. 5. All plans utilize a Prescription Drug Formulary which is a list of prescription drugs available to you and your doctor. If you choose a drug that is not on the formulary, you will responsible for a higher copay for the non-formulary drug. 6. Some specific benefits may have limitations. Premier Plus and Value Plan out-of-network benefits pay at 60% of the out-of-network rate after the deductible has been met. Your provider may charge you more than the out-of-network rate. You will be responsible for any charges over the out-of-network rate and these charges will not apply to your deductible, or maximum out of pocket. 7. Members may self refer to these services. 8. Out-of-Network preventative services are limited to routine examinations, well child care and immunizations, up to payment of $250 per person per plan year. 9. There is a two year cap on the maximum amount on the HRA account.

5 ADDITIONAL PROTECTION DENTAL COVERAGE TWO OPTION PLAN You may select one of the two dental options for you and eligible dependents, regardless of whether or not you enroll for the medical coverage. If you elect dependent dental coverage, you and all eligible dependents must elect the same plan option. You may only change plan options at annual open enrollments, subject to plan limitations. Plan Basic Dental PPO is a traditional dental plan which provides reimbursements for many procedures. You have the freedom to choose any provider, including specialists. Benefits are paid after any applicable deductible has been met, up to the annual maximum. Claim payments may be made to you or your dentist, whichever you prefer, unless benefits have been assigned to the provider. Type I charges are paid at 00% of the Allowable Charge with no deductible. Type II charges are paid at 80% of the Allowable Charge, after the $50 per person deductible. There is a $,500 annual plan maximum per person. There is no coverage for Type III and orthodontic expense. Plan 2 Advance Dental PPO is similar to Plan 2 but includes coverage for Type III and orthodontic expense. Like Plan 2, you may choose any provider and benefits are subject to a $50 per person deductible and $,500 plan maximum. The deductible is waived for preventive care. Type III expenses get 25% the first year, then 50% there after, both based on the Allowable Charge. These are brief descriptions only and not certificates of coverage. The Group Policy alone determines all rights, benefits, and exclusions. Indemnity plans are underwritten through MetLife. VISION INSURANCE - EyeMed If you enroll for medical coverage, you are eligible to enroll in vision. If you enroll in a medical plan, you are allowed one annual vision exam by an SRHS or Coventry participating ophthalmologist. You can purchase insurance which covers one annual vision examination plus one set of frames, eyeglass lenses or contacts. See plan description for details and copayments - EyeMed. FLEIBLE SPENDING/ REIMBURSEMENT ACCOUNTS Healthcare and dependent care reimbursement accounts allow you to set aside pretax dollars to reimburse yourself for expenses that are not covered by any of the benefit plans. Because the dollars you set aside are contributed to your account before income and Social Security taxes are withheld, you get a tax advantage. Unused funds are forfeited at the end of the year. Eligible expenses include: Healthcare account any expenses up to the maximum of $2,500 a year not reimbursed by your medical, dental or vision plan, such as deductibles, out-of-pocket expenses or care considered tax deductible but not covered by any plan. Dependent care account licensed, dependent care expenses for children under age 3 or elderly or disabled adults care up to a maximum of $5,000 a year. Contact your Human Resources department to learn more about these plans. DISABILITY INCOME PROTECTION Your long-term disability (LTD) coverage works with disability benefits you receive from other sources like Social Security to replace 60% of your base pay when you ve been unable to work for 90 days because of total disability. This LTD coverage is provided to full time employees who have at least one full year of continuous full-time service. It is provided at no cost to you. Contact your Human Resources department for more information of how disability is defined and how long benefits are payable. LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Basic Life and AD&D for you. It is provided at no cost to you. Your life insurance benefits are payable to the beneficiary you name. The basic life insurance, provided to full-time and regular part-time eligible employees, is one and one-half times your annual base pay to a maximum of $500,000. As an eligible employee you ll have basic AD&D insurance in an amount equal to your basic life insurance. Supplemental life insurance coverage for you If you need more life insurance, you have the option to buy up to four times your annual base pay as additional coverage. The maximum amount of supplemental coverage is $600,000. Options 2 Who Spouse/Children Spouse/Children How Much one half of employee optional amount ($00,000 maximum) or $50,000 with Evidence of Insurability/$0,000 $5,000/$5,000 Dependent life insurance coverage for your family If you elect optional coverage, you can also buy life insurance for eligible family members; however, if employee and spouse are both employees of any SRHS facility, they cannot be an insured person and a dependent, and only one eligible spouse may cover eligible children. If you purchase insurance for your children, the amount you select applies to all eligible children. You will be the beneficiary of any family coverage you choose. Refer to your life insurance booklet for how pay is defined and how much optional coverage you can buy. BENEFITS FOR YOUR RETIREMENT Supplemental Retirement Savings Plan (Defined Contribution Plan) Employees are able to set aside, on a pretax basis, a maximum of $7,500 into a 403(b) Retirement Account established through Lincoln Financial Group. Employees who are age 50 or older may contribute an additional $5,500 and employees with 5 or more years of service may contribute an additional $3,000. The money you set aside and any investment earnings are not taxed until it is paid out to you. The safe harbor matching contribution will be a 00% (dollar-for-dollar) matching contribution on your salary deferrals or Roth contributions up to 3% of compensation plus a 50% matching contribution on your salary deferrals or Roth contributions between 3% and 5% of compensation. The safe harbor matching contribution is based on salary deferrals you make during each payroll period during the Plan Year. You will be automatically enrolled in the plan unless you opt out. All contributions will be 00% vested immediately. credited service. Social Security All employee contributions to Social Security are matched. PAID TIME OFF (PTO)/ETENDED ILLNESS BANK (EIB) The PTO program lets you earn paid time off for personal use, such as vacation, holidays or sick leave, whether you are a full-time or parttime eligible employee. Your PTO is based on your length of service and is calculated from your hours worked each pay period.

6 Full-time service 0-4 years 5-7 years 8-4 years 5-9 years years years 30+ years PTO Accural Rates Maximum PTO (8 Hour Day) 22 days per year 27 days per year 28 days per year 3 days per year 32 days per year 33 days per year 34 days per year If you re a full-time employee, you will also accumulate paid time off for an extended illness through the extended illness bank (EIB) program up to a maximum of 520 hours. Full-time service Less than 4 years 5 or more years EIB Accural Rates Maximum EIB (8 Hour Day) 5 days per year 7 days per year ELIGIBILITY Most benefits are available to both regular and full-time (employed at least 64 hour per pay period) and regular part-time eligible employees (employed at least 30 hours per pay period). This chart shows when you become eligible for different employee benefits. Benefit Full-time Part-time When You re Eligible SOUTHERN REGIONAL HEALTH INSURANCE First day of month on or after 30 days of Dental Coverage Reimbursement accounts First day of month on or after 30 days of First day of month on or after 30 days of Optional vision insurance coverage First day of month on or after 30 days of Long-term disability insurance coverage After one year of continuous full-time employment Basic Life and AD&D insurance coverage First day of month following one year of Optional life insurance coverage Optional dependent life insurance coverage First day of month following 30 days of Supplemental retirement savings plan - 403(b) (Tax deferred annuity savings plan) Automatically enrolled first day of month on or after 30 days of Paid Time Off (PTO) Accrued from employment date; Accessible after three months of Extended Illness Bank (EIB) Accrued from employment date; Accessible after three months of CHANGES DURING A PLAN YEAR The decisions you make each year will stay in effect through the next December 3. Under federal law, your selections for any benefits that you pay for with pretax dollars go into effect on every January and will remain in effect for the full plan year unless a change in status such as: you get married or divorced your spouse or child dies, or you lose an eligible dependent for any reason you add an eligible dependent through birth, adoption or legal change of custody you or your eligible dependents lose medical coverage under your spouse s group plan you terminate employment You must notify your Human Resources department within 3 days of status change. ENROLLING FOR BENEFITS Think through the choices, and make your decision so you and your family can take advantage of the features that are right for you. Complete the enrollment forms included in this package, and make sure you fill in all the information requested, including the information on your dependents. If you have questions, contact your Human Resources employee benefits department at This brochure is only an overview of our benefit plans. Complete descriptions of the plans and their provisions are available to you. If any information in this brochure conflicts with the detailed plan documents, the plan documents are the authority. Though the system intends to continue providing these plans, the System reserves the right to make changes at any time. 0/203 CHGASR 805