Surgery required as the result of Morbid Obesity* INDIVIDUAL CALENDAR YEAR MAXIMUMS Acupuncture $2,000 Chiropractic Care $2,000

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1 AMHIC, A Reciprocal Association Effective January 1, 2019 Important Note: Do not rely on this chart alone. It is only a summary. The contents of this summary are subject to the provisions of the Benefit Booklet, which contains other and additional terms, covenants and conditions of coverage. The Plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required Plan procedures are followed (for example, the Plan may require pre-certification or the use of specified Providers). Payments to Providers are based on the, as determined by the Claims Administrator, in the amounts specified in the summary shown below. Covered Services are subject to the calendar year Deductible and pre-certification requirement, as indicated. Pre-Certification Requirement - The items marked below with an asterisk (*) require precertification. The Participant is responsible for ensuring that the pre-certification process is initiated when necessary. Failure to pre-certify will result in a penalty to the Participant. Please refer to Section 5 - Cost Containment Features. INDIVIDUAL LIFETIME MAXIMUMS Overall Medical Maximum Unlimited Hospice Care 180 days Surgery required as the result of Morbid Obesity* One surgery INDIVIDUAL CALENDAR YEAR MAXIMUMS Acupuncture $2,000 Chiropractic Care $2,000 Home Health Care 100 visits Infertility Testing $1,000 Skilled Nursing/Extended Care Facility 100 days * Pre-certification from the Managed Care Vendor is required. Contact it prior to admittance (or within one business day after an emergency admission) to a Network Hospital or other facility Provider, or a penalty of 50% up to a maximum of $500 will apply. Please call the Managed Care Vendor (Conifer) at (866) Out-of-Area Participating Providers (a provider that has a contractual agreement with Blue Cross and/or Blue Shield Licensees outside the MD/DC/Northern VA geographic area) are responsible for obtaining pre-certification for inpatient hospital or other facility admissions. DGX Network eff. January 1, January 1, 2019

2 Network Provider Non-Network Provider Type of Expense Out-of-Network) Deductible, per Calendar Year Individual NA Individual and 1 Dependent NA Family (Employee and 2 or more NA Dependents) Out-of-Pocket Maximum, per Calendar Year Individual $3,000 Individual and 1 Dependent $6,000 Family (Employee and 2 or more Dependents) $9,000 The out-of-pocket maximum is the maximum dollar amount you are responsible for paying for covered medical services and prescription drugs during a Calendar Year, including the Deductible, Coinsurance, and Copays. When your or your family's out-of-pocket expenses reach the out-of-pocket maximum, the Plan will pay 100% of the for the remainder of the Calendar Year. No family member will be charged more than the individual out-of-pocket maximum. Eligible expenses, including out-of-network and Ambulance, apply to the innetwork out-of-pocket maximum. A Copay is the flat dollar amount specified in the Schedule of Benefits that a Participant is required to pay for certain covered services. Copays will not apply after the out-of-pocket maximum has been reached. The following expenses do not apply to the out-of-pocket maximum: pre-certification penalties, non-covered services, and charges in excess of the. DGX Network eff. January 1, January 1, 2019

3 TYPE OF EXPENSE Hospital and Other Facility Expenses Inpatient* Includes room, board and ancillary services Inpatient Newborn Network Provider Non-Network Provider (Out-of-Network) $200 Copay per admission, then 100% of * $200 Copay per admission, then 100% of 80% of * Skilled Nursing/Extended Care Facility* Limited to 100 days per Calendar Year Rehabilitation Facility* 80% of * - Accidental Injury or Medical Emergency - for HIV screening - Non-Medical Emergency Outpatient includes all services billed by the Hospital $125 Copay, then 100% of Copay waived if admitted $125 Copay, then 100% of Copay waived if admitted 100% of 100% of Allowed Benefit 80% of 80% of Ambulatory Surgical Facility 80% of Professional Expenses Anesthesia - Inpatient and Outpatient 80% of 100% of 100% of - Accidental Injury or Medical Emergency 100% of 100% of - for HIV screening 80% of - Non-Medical Emergency Physician Hospital Visit 80% of Physician Office Visit - Primary Care Physician (PCP) (See Notes, #8 for definition of PCP) Physician Office Visit Specialist Physician Visit Telemedicine (MDLIVE) $25 Copay per visit, then 100% of $35 Copay per visit, then 100% of $10 Copay per visit, then 100% of * Pre-certification from the Managed Care Vendor is required. Contact it prior to admittance (or within one business day after an emergency admission) to a Network Hospital or other facility Provider, or a penalty of 50% up to a maximum of $500 will apply. Please call the Managed Care Vendor (Conifer) at (866) Out-of-Area Participating Providers (a provider that has a contractual agreement with Blue Cross and/or Blue Shield Licensees outside the MD/DC/Northern VA geographic area) are responsible for obtaining pre-certification for inpatient hospital or other facility admissions. DGX Network eff. January 1, January 1, 2019

4 TYPE OF EXPENSE Network Provider Non-Network Provider (Out-of-Network) Professional Expenses (con t) Second Surgical Opinion 80% of Surgery - Inpatient and Outpatient 80% of Other Eligible Expenses Acupuncture Limited to $2,000 per Calendar Year Allergy Shots/Serum If billed separately from office visit Allergy Testing - Primary Care Physician - Specialist Ambulance $35 Copay per visit, then 100% of 80% of $25 Copay, then 100% of $35 Copay, then 100% of $75 Copay, then 100% of $75 Copay, then 100% of Cardiac Rehabilitation 80% of Chiropractic Care Limited to $2,000 per Calendar Year 80% of Clinical Trials (Patient Costs) Covered according to place of service Durable Medical Equipment 80% of Home Health Care 80% of Limited to 100 visits per Calendar Year Hospice Care 100% of Limited to 180 days per Lifetime Infertility Testing 80% of Limited to $1,000 per Calendar Year Laboratory tests, x-rays and diagnostic 100% of tests, including specialty imaging Orthopedic Appliance 80% of Patient Education Includes diabetes management and ostomy care 80% of DGX Network eff. January 1, January 1, 2019

5 TYPE OF EXPENSE Network Provider Non-Network Provider (Out-of-Network) Other Eligible Expenses (con t) Pre-Admission Testing 80% of Private Duty Nursing 80% of Prosthetics 80% of Renal Dialysis 80% of Therapy Chemotherapy, Infusion, 80% of Radiation Therapy Physical, Occupational, 80% of Speech Urgent Care Center $50 Copay, then 100% of All Other Eligible Expenses 80% of Maternity Services Inpatient Hospital* $200 Copay per admission, then 100% of * Birthing Center 80% of Anesthesia 80% of Physician s Charges for Delivery 80% of Prenatal or postnatal office visits Not billed with delivery PCP $25 Copay per visit then 100% of Specialist $35 Copay per visit then 100% of 100% of Laboratory tests, x-rays, diagnostic tests, specialty imaging Prenatal Screening as defined under Women s Preventive Services, in compliance with the Patient Protection 100% of Not covered and Affordable Care Act of 2010 * Pre-certification from the Managed Care Vendor is required. Contact it prior to admittance (or within one business day after an emergency admission) to a Network Hospital or other facility Provider, or a penalty of 50% up to a maximum of $500 will apply. Please call the Managed Care Vendor (Conifer) at (866) Out-of-Area Participating Providers (a provider that has a contractual agreement with Blue Cross and/or Blue Shield Licensees outside the MD/DC/Northern VA geographic area) are responsible for obtaining pre-certification for inpatient hospital or other facility admissions DGX Network eff. January 1, January 1, 2019

6 TYPE OF EXPENSE Network Provider Non-Network Provider (Out-of-Network) Organ Transplants Inpatient Hospital* 80% of * Anesthesia 80% of Transplant Procedure 80% of Laboratory tests, x-rays, diagnostic 100% of tests Preventive Services Preventive Services for eligible adults and children, in compliance with the Patient Protection and Affordable Care Act of 2010** 100% of ** A description of Preventive Services can be found at: Women s Preventive Services, in compliance with the Patient Protection and Affordable Care Act of 2010*** 100% of *** A description of Women s Preventive Services can be found at: Nutritional Counseling 100% of Mental Health and Substance Abuse Inpatient Hospital or Residential Care in a Hospital or Non-Hospital Residential Facility* $200 Copay per admission, then 100% of * Inpatient Physician Visits 80% of Partial Hospitalization* $200 Copay per episode of care, then 100% of * Intensive Outpatient Services* $200 Copay per episode of care, then 100% of * Outpatient $25 Copay per visit, then 100% of * Pre-certification from the Managed Care Vendor is required. Contact it prior to admittance (or within one business day after an emergency admission) to a Network Hospital or other facility Provider, or a penalty of 50% up to a maximum of $500 will apply. Please call the Managed Care Vendor (Conifer) at (866) Out-of-Area Participating Providers (a provider that has a contractual agreement with Blue Cross and/or Blue Shield Licensees outside the MD/DC/Northern VA geographic area) are responsible for obtaining pre-certification for inpatient hospital or other facility admissions DGX Network eff. January 1, January 1, 2019

7 Retail Mail Order Prescription Drugs (30-day supply) (90-day supply) Generic Drugs $10 Copay $20 Copay Formulary Brand Name Drugs $35 Copay $70 Copay Non-Formulary Brand Name Drugs $70 Copay $140 Copay Out-of-pocket prescription drug expenses (Copays) apply to the medical plan s out-of-pocket maximum. After the medical plan s out-of-pocket maximum has been reached, prescription drugs will be reimbursed at 100% for the remainder of the Calendar Year. Over-the-Counter Drugs related to Preventive Services, in compliance with the Patient Protection and Affordable Care Act of 2010 A description of OTC drugs can be found at: FDA-Approved Generic Drugs and Over-the-Counter Drugs, Devices, and Supplies related to Women s Preventive Services, including FDA-approved contraceptive methods, in compliance with the Patient Protection and Affordable Care Act of 2010 A description of FDA-approved contraceptive methods can be found at: Brand Name (Chantix only) and Generic drugs and Over-the-Counter Drugs related to Smoking Cessation, in compliance with the Patient Protection and Affordable Care Act of 2010 A description of FDA-approved quit smoking medications and NRT s can be found at: Vaccination (age appropriate flu, shingles and pneumonia at Participating Network Pharmacies in the CareFirst Administrators MD/DC/Northern VA Service Area) A description of vaccines can be found at: Chemoprevention drugs, in compliance with the Patient Protection and Affordable Care Act of 2010 A description of chemoprevention drugs can be found at: NOTE: A Brand Name drug that has a Generic alternative is a Multisource Brand drug. If you are prescribed a Multisource Brand drug, and you purchase a Brand Name drug when a Generic drug is available, you will pay the Generic Copay plus the difference in price between the Brand Name drug and the Generic drug. You will be required to pay this difference, even if your Physician writes Dispense as Written. Over-the-Counter Option DGX Network eff. January 1, January 1, 2019

8 Non-sedating antihistamines and Prilosec (Please refer to Notes 9 and 10 below) $10 Copay NOTES: 1. Benefits for services provided by a Network Provider are payable as shown in this Summary of Benefits. To obtain In-Network benefits, you must use a Network Provider. Since the list of participating Network Providers is subject to change, it is best to confirm that a particular Provider participates by calling the Provider prior to receiving services. 2. Referrals by Network Providers to Non-Network Providers will be considered as Out-of-Network services and are not covered expenses. In order to receive In-Network benefits, ask your Physician to refer you to a Network Provider. However: a. If you utilize a Network Hospital or other facility which is a Network Provider and receive services from a Non-Network Provider; or b. If Medically Necessary services are not available from a Network Provider (because the network does not contract with the appropriate specialty), then the services will be paid at the In-Network benefit level, based on the. All other limitations, requirements and provisions of this Plan will apply. This exception does not apply in the event you and/or your Physician had the opportunity to select a Network Provider and chose to receive services from a Non-Network Provider. 3. The Copay in the Physician s office includes diagnostic services, injections, supplies, and allergy services performed in the office and billed by the Physician. 4. Anesthesia, x-rays, laboratory, emergency room services, inpatient consultations and other diagnostic services received at a Network Hospital or other facility Provider and rendered and billed by a Non- Network Provider will be paid at the In-Network benefit level, based on the. This exception does not apply if you and/or your Physician had the opportunity to select a Network Provider and chose to receive services from a Non-Network Provider. 5. If a Network Provider performs diagnostic testing, X-rays, and other laboratory testing and the Network Provider sends the tests to a Non-Network Provider (such as a laboratory) for analysis and results, the Plan will pay at the In-Network benefit level, based on the. 6. If the Participant receives care in an emergency room for an Accidental Injury or a Medical Emergency at a Non-Network Hospital, eligible expenses will be covered at the In-Network benefit level, based on the. If the Participant is admitted on an emergency basis to a facility, benefits for eligible expenses for that admission will be paid at the In-Network benefit level, based on the Allowed Benefit. 7. The is based on Plan allowances for treatment, services or supplies, rendered by a Provider, essential to the care of the individual as determined by the Claims Administrator. Charges by a Provider must be the amount usually charged for similar services and supplies in the absence of a plan or insurance. Charges for Covered Services that do not exceed the will be reimbursed as specified in this. A fee schedule, selected by the Claims Administrator, may be used by the Plan in determining the amount of the. 8. For purposes of determining copay amounts, a Primary Care Provider (PCP) is a physician practicing in the following disciplines: general practice, family practice, internal medicine, pediatrics, DGX Network eff. January 1, January 1, 2019

9 obstetrics/gynecology, or geriatrics; or a nurse practitioner. All other physicians are considered specialists. 9. Guidelines for Non-Sedating Antihistamines Non-sedating antihistamines may either be obtained in over-the-counter (OTC) form or dispensed by a pharmacist. Your Physician can prescribe either type. The following guidelines explain the benefits: - Over-the-Counter Benefits are provided for all over-the-counter non-sedating antihistamines at the Generic Copay. Examples include Claritin, Allegra, Clarinex and Zyrtec. Keep in mind that in order for the OTC drug to be covered, you must have a prescription from your Physician. - Pharmacist-dispensed Prescriptions Benefits are not provided for non-sedating antihistamines when dispensed by a pharmacist from a written prescription. In this case, you will pay the entire amount for the drug. 10. Guidelines for Prilosec Prilosec may either be obtained in over-the-counter (OTC) form or dispensed by a pharmacist. Your Physician can prescribe either type. The following guidelines explain the benefits: - Over-the-Counter Benefits are provided for over-the-counter Prilosec at the Generic Copay. Keep in mind that in order for OTC Prilosec to be covered, you must have a prescription from your Physician. - Pharmacist-dispensed Prescriptions Benefits are not provided for Prilosec when dispensed by a pharmacist from a written prescription. In this case, you will pay the entire amount for the drug. 11. Your employer may or will require you to pay for some portion or all of the applicable premium for the cost of coverage you elect under the Plan. DGX Network eff. January 1, January 1, 2019