INSIDE OUR PORTFOLIO - PDF Free Download

For Employer Groups Plans effective January 1, 2010

P3 P6 INSIDE OUR PORTFOLIO HMO Health Maintenance Organization plans Health Alliance HMO offers a large provider network and very low out-of-pocket costs. These plans are ideal for groups seeking comprehensive coverage, no deductibles and predictability for their employees. Our POS plans offer comprehensive HMO style benefits for in-network services and indemnity coverage for out-of-network services. Coverage level is determined at the point of service. P11 POS-C P15 POS Point of Service plans Point of Service Copayment plans Our POS-C plans feature all the characteristics of a POS plan with substantially lower premiums in exchange for higher cost sharing at the time of service. CCP Coordinated Care plans These hybrid plans combine the best traits of an HMO and a PPO and provide significant savings for employers. Employees have lower cost sharing in the narrower network and the flexibility of out-of-network coverage. P21 PPO Preferred Provider Organization plans PPO plans give members more freedom of choice in selecting a health care provider and offer lower out-of-pocket costs for in-network care. Higher deductible options provide for lower premiums and may also be paired with a consumer-driven solution. P29 QCCP Qualified Coordinated Care plans The Qualified CCPs combine the attractive design of our traditional CCP with the ability to benefit from Health Savings Account tax advantages. P32 QHDHP Qualified High Deductible Health plans Qualified high deductible health plans are PPO plans that combine employee involvement in managing their health care with tax advantages. P40 CDHP Consumer-Driven Health plans Health Alliance partners with Benefit Planning Consultants, Inc. (BPC) to administer these solutions for employee engagement in managing health care spending. P43 HEALTH PLAN TERMINOLOGY

Health Alliance Claims Payment Done Right!!!! Over the last five years, Health Alliance has processed more than 14 million claims with 99% accuracy. 90% of claims are processed within 13.3 working days. Nine out of 10 members agree Health Alliance handles their claims correctly and quickly. 83% of claims are system processed requiring minimal human intervention. Problems Solved Quickly, Completely! 84.8% of our employer clients agree that their Health Alliance account representative quickly resolves any problems. The national average is 65%.! 85.1% of our employer clients agree that their Health Alliance account representative is empowered and flexible to address their needs. The national average is 62%.! 82% of calls to Customer Service are answered within 30 seconds.! Average telephone answer speed is 18.3 seconds.! 99% of the time our Customer Service reps are able to resolve member issues on the first call. Customer Satisfaction Required! Health Alliance has scored in the Top 10% nationally for members overall rating of their health plan eight out of the last 10 years.! 79.2% of our employer clients say they are likely to recommend Health Alliance. The national average is 47.2%.! Maintained highest possible National Committee on Quality Assurance rating since 1996.! 79.1% of our employer groups of at least 25 employees have been with us for two years or more, compared to a national average of 65.6%. 1

Extras Help Members Focus on Health Beyond great health care coverage, all Health Alliance standard benefit plans feature the following services to help keep members healthy. The best part? They re at no additional cost. Comprehensive Wellness Coverage We cover wellness services and tests for everyone on the plan, including dependents. Our wellness benefit helps keep members healthy by covering:! One wellness exam per plan year! One visit to a Women s Principal Health Care Provider per year! Well-child care, including immunizations! Essentials like cholesterol and cervical cancer screenings Health Exchange Our Health Exchange programs help people with chronic conditions like asthma, diabetes and high blood pressure. Members are better able to manage their conditions with extra attention from Health Alliance, as well as resources that focus on healthy living. Personal Health Coordination Personal health coordinators are registered nurses who take the fear and confusion out of chronic conditions, treatment options, hospital stays and more. They ll even speak with providers for members to coordinate care. And they ll call eligible members to see how they re feeling and what kind of help they need. WorldDoc WorldDoc at www.healthalliance.org helps employees understand health risks, illnesses, treatment options and medications through innovative tools and resources. Around-the-clock access to WorldDoc makes challenging health decisions a little easier, including a symptom evaluator that helps members decide what to treat at home and when to see their doctor. My Drug Benefit Health Alliance members with pharmacy benefits can view their pharmacy claims and copayment information on our website. They can also research drug information and compare costs. Our Value-Based Benefit Members receive some medications used to treat asthma, high cholesterol, high blood pressure and diabetes at a lower cost through our Value-Based Benefit. COBRA Administration We offer complete outsourcing for COBRA administration that makes COBRA hasslefree for employers by coordinating notices, collecting premiums and tracking eligibility timelines. 2

STRUCTURE! Only care received within the HMO network is covered. Out-of-network coverage is available in emergencies or when prior authorization is given.! Members choose a Primary Care Physician (PCP) to coordinate all medical care.! For specialty care, a PCP gives a referral to a Health Alliance HMO network specialist.! Women can select a Women s Principal Health Care Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP. CONSIDERATIONS! Our HMO networks are extensive and feature premier providers in each of our service areas.! Members never have to pay a deductible before coverage begins.! Flat copayments for office visits and other services keep medical expenses predictable and budget-friendly.! A PCP gives attention to your personalized, overall health and serves as your health care partner. Alexander Decatur East Central Illinois Macomb Peoria Quad Cities Pulaski Wabash Edwards Quincy Southern Illinois Springfield Sterling/Rock Falls Each color represents a unique and distinct service area/provider network. An employer s location and employee s home address determine which HMO provider network(s) are available. 4

Plan Design HMO 100 HMO 90 HMO 80 Member Benefits In-Network Only In-Network Only In-Network Only Plan Pays 100% 90% 80% After applicable member copayment or Plan Year Deductible N/A N/A N/A Family: $3,000 Family: $3,000 Family: $3,000 Lifetime Maximum Benefit Unlimited Unlimited Unlimited Be Well: Preventive Services $0 copayment $0 copayment $0 copayment Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/frequency schedules. Primary Care Office Visit $20 copayment $20 copayment $20 copayment Specialist Office Visit $40 copayment $40 copayment $40 copayment Routine Prenatal Care $100 copayment per 10% 20% pregnancy Outpatient and Diagnostic Testing $0 copayment 10% 20% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures $100 copayment 10% 20% Inpatient Hospitalization $50 copayment per day 10% 20% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment Emergency Department $100 copayment $100 copayment $100 copayment Transportation Spinal Manipulations $15 copayment $15 copayment $20 copayment Durable Medical Equipment and 20% 20% 20% Prosthetic Devices* Eye Exams* $40 copayment $40 copayment $40 copayment Value-Based Drugs* 10% 10% 10% Prescription Drugs -- Tier 1* $15 copayment $15 copayment $15 copayment Prescription Drugs -- Tier 2* $30 copayment $30 copayment $30 copayment Prescription Drugs -- Tier 3* $50 copayment $50 copayment $50 copayment Specialty Prescription Drugs* Preauthorization required 20% 20% 20% Specialty Prescription Drugs *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 5

STRUCTURE! Coverage is determined at the point of service, dependent on the provider chosen. When choosing a Health Alliance network provider, HMO style benefits. When choosing an out-of-network provider, indemnity benefits except in cases of emergency or when prior authorization is given.! Members select a PCP to coordinate all medical care.! For in-network specialty care, a PCP gives a referral to a Health Alliance participating specialist. Specialty care sought without a referral or out-of-network is covered at the lower, indemnity level.! Women can select a Women s Principal Health Care Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP. Alexander Pulaski Edwards Wabash CONSIDERATIONS! POS plans are a combination of HMO financial advantages no deductible, fixed copayments, an annual out-of-pocket maximum with the choice of out-of-network care at a limited (indemnity) coverage level.! Our POS networks are extensive and feature premier providers in each of our service areas.! A PCP gives attention to your personalized, overall health and serves as your health care partner. Decatur East Central Illinois Macomb Peoria Quad Cities Quincy Southern Illinois Springfield Sterling/Rock Falls Each color represents a unique and distinct service area/provider network. An employer s location and employee s home address determine which provider network(s) are available. 8

Plan Design POS 100 POS 90 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 80% 90% 60% Plan Year Deductible N/A Single: $500 Family: $1,500 Plan Year Out-of-Pocket Maximum Includes deductible expenses Family: $3,000 Single: $2,000 Family: $6,000 N/A Single: $750 Family: $2,250 Family: $3,000 Single: $3,000 Family: $9,000 Lifetime Maximum Benefit Unlimited $1,000,000 Unlimited $1,000,000 Be Well: Preventive Services $0 copayment 20% $0 copayment 40% Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit $20 copayment 20% $20 copayment 40% Specialist Office Visit $40 copayment 20% $40 copayment 40% Routine Prenatal Care $100 copayment 20% 10% 40% per pregnancy Outpatient and Diagnostic $0 copayment 20% 10% 40% Testing X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures $100 copayment 20% 10% 40% Inpatient Hospitalization Including Maternity Care $50 copayment per day 20% 10% 40% Emergency Department Visits $175 copayment $175 copayment Emergency Department Transportation $100 copayment $100 copayment Spinal Manipulations $15 copayment 50% Durable Medical Equipment and Prosthetic Devices* $175 copayment $175 copayment $100 copayment $100 copayment $15 copayment 50% 20% not covered 20% not covered Eye Exams* $40 copayment not covered $40 copayment not covered Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs * 20% 50% 20% 50% Specialty Prescription Drugs Single: N/A Family: N/A Single: N/A Family: N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 9

Plan Design POS 80 POS 70 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 50% 70% 50% Plan Year Deductible N/A Single: $750 Family: $2,250 Plan Year Out-of-Pocket Maximum Includes deductible expenses Family: $3,000 Single: $4,000 Family: $12,000 N/A Single: $1,000 Family: $3,000 Family: $3,000 Single: $5,000 Family: $15,000 Lifetime Maximum Benefit Unlimited $1,000,000 Unlimited $1,000,000 Be Well: Preventive Services $0 copayment 50% $0 copayment 50% Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit $20 copayment 50% $20 copayment 50% Specialist Office Visit $40 copayment 50% $40 copayment 50% Routine Prenatal Care 20% 50% 30% 50% Outpatient and Diagnostic 20% 50% 30% 50% Testing X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 50% 30% 50% Inpatient Hospitalization Including Maternity Care 20% 50% 30% 50% Emergency Department Visits $175 copayment $175 copayment Emergency Department Transportation $100 copayment $100 copayment Spinal Manipulations $20 copayment 50% Durable Medical Equipment and Prosthetic Devices* $175 copayment $175 copayment $100 copayment $100 copayment $20 copayment 50% 20% not covered 30% not covered Eye Exams* $40 copayment not covered $40 copayment not covered Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs * 20% 50% 20% 50% Specialty Prescription Drugs Single: N/A Family: N/A Single: N/A Family: N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 10

STRUCTURE! Coverage is determined at the point of service, dependent on the provider chosen. When choosing a Health Alliance network provider, HMO style benefits. When choosing an out-of-network provider, indemnity benefits.! Members select a PCP to coordinate all medical care.! For in-network specialty care, a PCP gives a referral to a Health Alliance participating specialist. Specialty care sought without a referral or out-of-network is covered at the lower, indemnity level.! Women can select a Women s Principal Health Care Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP. CONSIDERATIONS! Premium rates for POS-C plans are very competitive. Copayments are higher than traditional POS plans for some services.! This product is a combination of HMO financial advantages no deductible, fixed copayments, an annual out-of-pocket maximum and the choice of out-of-network care covered at a limited (indemnity) level.! Seeking care from preferred providers is vital to POS-C cost effectiveness. Health Alliance has discounts with those providers, allowing us to pass significant savings to employers.! A PCP gives attention to your personalized, overall health and serves as your health care partner. East Central Illinois Peoria Springfield Alexander Pulaski Edwards POS-C plans fit best in these counties Wabash Each color represents a unique and distinct service area/provider network. An employer s location and employee s home address determine which provider network(s) are available. 12

Plan Design POS-C 250 POS-C 500 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 50% 100% 50% Plan Year Deductible N/A Single: $5,000 Family: $10,000 Includes deductible expenses Single: $2,250 Single: $10,000 Family: $20,000 N/A Single: $5,000 Family: $10,000 Single: $2,500 Family: $5,000 Single: $10,000 Family: $20,000 Lifetime Maximum Benefit Unlimited $1,000,000 Unlimited $1,000,000 Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. $0 copayment 50% $0 copayment 50% Primary Care Office Visit $20 copayment 50% $20 copayment 50% Specialist Office Visit $40 copayment 50% $40 copayment 50% Routine Prenatal Care 20% 50% 20% 50% Diagnostic Tests and X-rays 20% 50% 20% 50% MRI and CT $250 copayment, then 20% 50% $500 copayment, then 20% 50% Outpatient Surgery/Procedures Inpatient Hospitalization Including Maternity Care $250 copayment, then 20% $250 copayment, then 20% Emergency Department Visits $175 copayment $175 copayment Emergency Department Transportation $100 copayment $100 copayment Spinal Manipulations 50% 50% Durable Medical Equipment and Prosthetic Devices* 50% $500 copayment, then 20% 50% $500 copayment, then 20% 50% 50% $175 copayment $175 copayment $100 copayment $100 copayment 50% 50% 20% not covered 20% not covered Eye Exams* $40 copayment not covered $40 copayment not covered Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* Preauthorization required 20% 50% 20% 50% Specialty Prescription Drugs Single: N/A Family: N/A Single: N/A Family: N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 13

Plan Design POS-C 1000 POS-C 1500 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 50% 100% 50% Plan Year Deductible N/A Single: $5,000 Family: $10,000 Includes deductible expenses Single: $3,000 Family: $6,000 Single: $10,000 Family: $20,000 N/A Single: $5,000 Family: $10,000 Single: $3,000 Family: $6,000 Single: $10,000 Family: $20,000 Lifetime Maximum Benefit Unlimited $1,000,000 Unlimited $1,000,000 Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. $0 copayment 50% $0 copayment 50% Primary Care Office Visit $20 copayment 50% $20 copayment 50% Specialist Office Visit $40 copayment 50% $40 copayment 50% Routine Prenatal Care 20% 50% 20% 50% Diagnostic Tests and X-rays 20% 50% 20% 50% MRI and CT $500 copayment, then 20% 50% $750 copayment, then 20% 50% Outpatient Surgery/Procedures Inpatient Hospitalization Including Maternity Care $1,000 copayment, then 20% $1,000 copayment, then 20% Emergency Department Visits $175 copayment $175 copayment Emergency Department Transportation $100 copayment $100 copayment Spinal Manipulations 50% 50% Durable Medical Equipment and Prosthetic Devices* 50% $1,500 copayment, then 20% 50% $1,500 copayment, then 20% 50% 50% $175 copayment $175 copayment $100 copayment $100 copayment 50% 50% 20% not covered 80% not covered Eye Exams* $40 copayment not covered $40 copayment not covered Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* Preauthorization required 20% 50% 20% 50% Specialty Prescription Drugs Single: N/A Family: N/A Single: N/A Family: N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. 14 This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans.

d d STRUCTURE! Coverage is determined at the point of service, dependent on the provider chosen. When choosing a Health Alliance network provider, HMO style benefits.! The CCP is a PPO plan with considerably lower out-of-pocket costs for in-network care vs. out-of-network care.! After members meet the in-network and/or out-of-network deductible, Health Alliance pays a portion of covered charges.! Members select a PCP from our network to coordinate all medical care.! For specialty care, a PCP gives a referral to an in-network specialist. Specialty care sought without a referral or outside the provider network is covered at the lower level.! Women can select a Women s Principal Health Care Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP. d d d d d d Alexander d dd Pulaski d d d d Wabash Edwards CONSIDERATIONS! The CCP marries the best aspects of an HMO and a PPO lower, controlled costs and the flexibility to seek treatment from the physician of your choice.! Seeking care from network providers is vital to CCP cost effectiveness. Health Alliance has discounts with these providers, allowing us to pass significant savings (over a traditional PPO plan) to both members and employers.! Outside the limited marketable CCP service area, the POS-C is a great alternative. See page 11 for more information about POS-C plans. d CCP 2000, CCP 2500, CCP 3000 and CCP 5000 are best-suited for these counties 16

Plan Design CCP 250 CCP 500 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 50% 80% 50% Plan Year Deductible Single: $250 Family: $500 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Specialist Office Visit Single: $2,250 $0 copayment $20 copayment $40 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 Single: $500 Family: $1,000 Single: $2,500 Family: $5,000 $5,000,000 $5,000,000 50% $0 copayment 50% $20 copayment 50% $40 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 50% 50% 50% Routine Prenatal Care 20% 50% 20% 50% Outpatient and Diagnostic Testing 20% 50% 20% 50% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 50% 20% 50% Inpatient Hospitalization 20% 50% 20% 50% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 17

Plan Design CCP 1000 CCP 1500 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 50% 80% 50% Plan Year Deductible Single: $1,000 Family: $2,000 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Specialist Office Visit Single: $3,000 Family: $6,000 $0 copayment $20 copayment $40 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 Family: $3,000 Single: $3,500 Family: $7,000 $5,000,000 $5,000,000 50% $0 copayment 50% $20 copayment 50% $40 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 50% 50% 50% Routine Prenatal Care 20% 50% 20% 50% Outpatient and Diagnostic Testing 20% 50% 20% 50% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 50% 20% 50% Inpatient Hospitalization 20% 50% 20% 50% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 18

Plan Design CCP 2000 CCP 2500 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 50% 80% 50% Plan Year Deductible Single: $2,000 Family: $4,000 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Specialist Office Visit Single: $4,000 Family: $8,000 $0 copayment $20 copayment $40 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 Single: $2,500 Family: $5,000 Single: $4,500 Family: $9,000 $5,000,000 $5,000,000 50% $0 copayment 50% $20 copayment 50% $40 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 50% 50% 50% Routine Prenatal Care 20% 50% 20% 50% Outpatient and Diagnostic Testing 20% 50% 20% 50% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 50% 20% 50% Inpatient Hospitalization 20% 50% 20% 50% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 19

Plan Design CCP 3000 CCP 5000 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 50% 80% 50% Plan Year Deductible Single: $3,000 Family: $6,000 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Specialist Office Visit Single: $5,000 Family: $10,000 $0 copayment $20 copayment $40 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 Single: $5,000 Family: $10,000 Single: $7,000 Family: $14,000 $5,000,000 $5,000,000 50% $0 copayment 50% $20 copayment 50% $40 copayment Single: $10,000 Family: $20,000 Single: $20,000 Family: $40,000 50% 50% 50% Routine Prenatal Care 20% 50% 20% 50% Outpatient and Diagnostic Testing 20% 50% 20% 50% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 50% 20% 50% Inpatient Hospitalization 20% 50% 20% 50% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 20

STRUCTURE! While PPO members can choose any provider they want, receiving care from a network provider ensures coverage at the highest benefit level.! Members are not required to select a PCP to coordinate care.! Health Alliance does not require that PPO members get a formal referral for specialty care, although some physician practices may require it. Edwards Wabash CONSIDERATIONS! While Health Alliance has thousands of preferred physicians, hospitals, pharmacies and other providers in-network throughout Illinois, we also offer access to national networks for employees in other states. Alexander Pulaski 22

Plan Design PPO 250 90/70 PPO 250 80/60 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 90% 70% 80% 60% Plan Year Deductible Single: $250 Family: $500 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Deductible does not Specialist Office Visit Deductible does not Single: $2,250 $0 copayment $20 copayment $40 copayment Single: $500 Family: $1,000 Single: $3,500 Family: $7,000 Single: $250 Family: $500 Single: $2,250 $5,000,000 $5,000,000 30% $0 copayment 30% $20 copayment 30% $40 copayment Single: $500 Family: $1,000 Single: $3,500 Family: $7,000 40% 40% 40% Routine Prenatal Care 10% 30% 20% 40% Outpatient and Diagnostic Testing 10% 30% 20% 40% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 10% 30% 20% 40% Inpatient Hospitalization 10% 30% 20% 40% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 23

Plan Design PPO 500 90/70 PPO 500 80/60 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 90% 70% 80% 60% Plan Year Deductible Single: $500 Family: $1,000 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Deductible does not Specialist Office Visit Deductible does not Single: $2,500 Family: $5,000 $0 copayment $20 copayment $40 copayment Single: $1,000 Family: $2,000 Single: $4,000 Family: $8,000 Single: $500 Family: $1,000 Single: $2,500 Family: $5,000 $5,000,000 $5,000,000 30% $0 copayment 30% $20 copayment 30% $40 copayment Single: $1,000 Family: $2,000 Single: $4,000 Family: $8,000 40% 40% 40% Routine Prenatal Care 10% 30% 20% 40% Outpatient and Diagnostic Testing 10% 30% 20% 40% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 10% 30% 20% 40% Inpatient Hospitalization 10% 30% 20% 40% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. 24 This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans.

Plan Design PPO 1000/2000 80/60 PPO 1000/3000 80/60 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 60% 80% 60% Plan Year Deductible Single: $1,000 Family: $2,000 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Deductible does not Specialist Office Visit Deductible does not Single: $3,000 Family: $6,000 $0 copayment $20 copayment $40 copayment Single: $2,000 Family: $4,000 Single: $6,000 Family: $12,000 Single: $1,000 Family: $3,000 Single: $3,500 Family: $8,000 $5,000,000 $5,000,000 40% $0 copayment 40% $20 copayment 40% $40 copayment Single: $2,000 Family: $6,000 Single: $12,000 Family: $26,000 40% 40% 40% Routine Prenatal Care 20% 40% 20% 40% Outpatient and Diagnostic Testing 20% 40% 20% 40% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 40% 20% 40% Inpatient Hospitalization 20% 40% 20% 40% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 25

Plan Design PPO 1500 80/60 PPO 2000 80/60 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 60% 80% 60% Plan Year Deductible Family: $3,000 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Deductible does not Specialist Office Visit Deductible does not Single: $3,500 Family: $7,000 $0 copayment $20 copayment $40 copayment Single: $3,000 Family: $6,000 Single: $7,000 Family: $14,000 Single: $2,000 Family: $4,000 Single: $4,000 Family: $8,000 $5,000,000 $5,000,000 40% $0 copayment 40% $20 copayment 40% $40 copayment Single: $4,000 Family: $8,000 Single: $8,000 Family: $16,000 40% 40% 40% Routine Prenatal Care 20% 40% 20% 40% Outpatient and Diagnostic Testing 20% 40% 20% 40% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 40% 20% 40% Inpatient Hospitalization 20% 40% 20% 40% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. 26 This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans.

Plan Design PPO 2500 80/60 PPO 5000 80/60 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 60% 80% 60% Plan Year Deductible Single: $2,500 Family: $5,000 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Deductible does not Specialist Office Visit Deductible does not Single: $4,500 Family: $9,000 $0 copayment $20 copayment $40 copayment Single: $5,000 Family: $10,000 Single: $9,000 Family: $18,000 Single: $5,000 Family: $10,000 Single: $7,000 Family: $14,000 $5,000,000 $5,000,000 40% $0 copayment 40% $20 copayment 40% $40 copayment Single: $10,000 Family: $20,000 Single: $14,000 Family: $28,000 40% 40% 40% Routine Prenatal Care 20% 40% 20% 40% Outpatient and Diagnostic Testing 20% 40% 20% 40% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 40% 20% 40% Inpatient Hospitalization 20% 40% 20% 40% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 20% 50% 20% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 27

Plan Design PPO 7500 100/60 PPO 10,000 100/60 Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 60% 100% 60% Plan Year Deductible Single: $7,500 Family: $15,000 Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Primary Care Office Visit Deductible does not Specialist Office Visit Deductible does not Single: $7,500 Family: $15,000 $0 copayment $20 copayment $40 copayment Single: $15,000 Family: $30,000 Single: $20,000 Family: $40,000 Single: $10,000 Family: $20,000 Single: $10,000 Family: $20,000 $5,000,000 $5,000,000 40% $0 copayment 40% $20 copayment 40% $40 copayment Single: $20,000 Family: $40,000 Single: $25,000 Family: $50,000 40% 40% 40% Routine Prenatal Care 0% 40% 0% 40% Outpatient and Diagnostic Testing 0% 40% 0% 40% X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 0% 40% 0% 40% Inpatient Hospitalization 0% 40% 0% 40% Including Maternity Care Emergency Department Visits $175 copayment $175 copayment $175 copayment $175 copayment Deductible does not Emergency Department Transportation Deductible does not $100 copayment $100 copayment $100 copayment $100 copayment Spinal Manipulations* In- and out-of-network Durable Medical Equipment and Prosthetic Devices* Eye Exams* 50% 50% 0% 50% 0% 50% $40 copayment 50% $40 copayment 50% Value-Based Drugs* 10% 50% 10% 50% Prescription Drugs -- Tier 1* $15 copayment 50% $15 copayment 50% Prescription Drugs -- Tier 2* $30 copayment 50% $30 copayment 50% Prescription Drugs -- Tier 3* $50 copayment 50% $50 copayment 50% Specialty Prescription Drugs* 20% 50% 20% 50% Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. 28 This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans.

STRUCTURE! The QCCP is a qualified CCP plan with considerably lower out-of-pocket costs for in-network vs. out-of-network provider care. With a QCCP, employers can create a Consumer-Driven Health Plan (CDHP). Refer to page 40 for more information on our CDHP solutions.! After members meet the in-network and/or out-of-network provider deductible, Health Alliance pays a portion of covered charges.! Pharmacy claims are subject to the deductible.! Members select a PCP from our network providers to coordinate all medical care.! For in-network specialty care, a PCP gives a referral to a participating specialist. Specialty care sought without a referral is covered at the lower, out-of-network level.! Women can select a Women s Principal Health Care Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP. Edwards Wabash CONSIDERATIONS! A QCCP is eligible to be combined with a Health Savings Account (HSA) as an attractive tax-advantaged strategy. Also, a QCCP plan s higher deductible lowers the premium cost.! Members pay for covered services, not copayments.! Seeking care from network providers is vital to QCCP cost effectiveness. Health Alliance has discounts with these providers, allowing us to pass significant savings (over a traditional PPO plan) to both members and employers.! Like all Health Alliance plans, QCCPs offer first-dollar preventive coverage for routine physicals, immunizations, screenings and more. Pulaski Alexander 30

Plan Design QCCP 1500 80/50 - Aggregate Deductible QCCP 2500 80/50 - Aggregate Deductible Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 80% 50% 80% 50% Plan Year Deductible Family: $3,000 Plan Year Out-of-Pocket Maximum Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Single: $4,000 Family: $8,000 $0 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 Single: $2,500 Family: $5,000 Single: $5,000 Family: $10,000 $5,000,000 $5,000,000 50% $0 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 50% Primary Care Office Visit 20% 50% 20% 50% Specialist Office Visit 20% 50% 20% 50% Routine Prenatal Care 20% 50% 20% 50% Outpatient and Diagnostic 20% 50% 20% 50% Testing X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 20% 50% 20% 50% Inpatient Hospitalization 20% 50% 20% 50% Including Maternity Care Emergency Department Visits 20% 20% 20% 20% Emergency Department Transportation 20% 20% 20% 20% Spinal Manipulations In- and out-of-network Durable Medical Equipment and Prosthetic Devices 20% In-network deductible applies 20% In-network deductible applies 20% 50% * 20% 50% * Eye Exams 20% 50% * 20% 50% * Value-Based Drugs 10% 50% * 10% 50% * Prescription Drugs -- Tier 1 20% 50% * 20% 50% * Prescription Drugs -- Tier 2 20% 50% * 20% 50% * Prescription Drugs -- Tier 3 20% 50% * 20% 50% * Specialty Prescription Drugs Preauthorization required 20% 50% * 20% 50% * *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 31

STRUCTURE! Qualified High Deductible Health Plans are PPO plans qualified to pair with an HSA to create a Consumer-Driven Health Plan solution. Turn to page 40 for more information.! Health Alliance QHDHPs include embedded deductibles on select plans, in addition to the traditional aggregate deductible. See page 44 for more information.! Members are not required to select a Primary Care Physician (PCP) to coordinate care.! Health Alliance does not require that QHDHP members get a formal referral for specialty care. Edwards Wabash CONSIDERATIONS! Since a QHDHP has a higher deductible than a traditional PPO, premiums are typically lower.! Pharmacy claims are subject to the deductible.! Members pay for covered services rather than copayments.! Seeking care from network providers is vital to QHDHP cost effectiveness. Health Alliance has discounts with these providers, allowing us to pass savings (over a traditional PPO plan) to both members and employers.! Like all Health Alliance plans, QHDHPs offer first-dollar coverage for routine physicals, immunizations, screenings and more. Alexander Pulaski 34

Plan Design QHDHP 1500 100/50 - Aggregate Deductible QHDHP 1500 80/60 - Aggregate Deductible Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 50% 80% 60% Plan Year Deductible Family: $3,000 Plan Year Out-of-Pocket Maximum Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Family: $3,000 $0 copayment Single: $3,000 Family: $6,000 Single: $8,000 Family: $16,000 Family: $3,000 Single: $4,000 Family: $8,000 $5,000,000 $5,000,000 50% $0 copayment Single: $3,000 Family: $6,000 Single: $8,000 Family: $16,000 40% Primary Care Office Visit 0% 50% 20% 40% Specialist Office Visit 0% 50% 20% 40% Routine Prenatal Care 0% 50% 20% 40% Outpatient and Diagnostic 0% 50% 20% 40% Testing X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 0% 50% 20% 40% Inpatient Hospitalization 0% 50% 20% 40% Including Maternity Care Emergency Department Visits 0% 0% 20% 20% Emergency Department Transportation 0% 0% 20% 20% Spinal Manipulations In- and out-of-network Durable Medical Equipment and Prosthetic Devices 0% In-network deductible applies 20% In-network deductible applies 0% 50% * 20% 50% * Eye Exams 0% 50% * 20% 50% * Value-Based Drugs 0% 50% * 10% 50% * Prescription Drugs -- Tier 1 0% 50% * 20% 50% * Prescription Drugs -- Tier 2 0% 50% * 20% 50% * Prescription Drugs -- Tier 3 0% 50% * 20% 50% * Specialty Prescription Drugs 0% 50% * 20% 50% * Preauthorization required Specialty Prescription Drugs N/A N/A N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 35

Plan Design QHDHP 2000 100/50 - Aggregate Deductible QHDHP 2000 80/60 - Aggregate Deductible Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 50% 80% 60% Plan Year Deductible Single: $2,000 Family: $4,000 Plan Year Out-of-Pocket Maximum Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Single: $2,000 Family: $4,000 $0 copayment Single: $4,000 Family: $8,000 Single: $10,000 Family: $20,000 Single: $2,000 Family: $4,000 Single: $5,000 Family: $10,000 $5,000,000 $5,000,000 50% $0 copayment Single: $4,000 Family: $8,000 Single: $10,000 Family: $20,000 40% Primary Care Office Visit 0% 50% 20% 40% Specialist Office Visit 0% 50% 20% 40% Routine Prenatal Care 0% 50% 20% 40% Outpatient and Diagnostic 0% 50% 20% 40% Testing X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 0% 50% 20% 40% Inpatient Hospitalization 0% 50% 20% 40% Including Maternity Care Emergency Department Visits 0% 0% 20% 20% Emergency Department Transportation 0% 0% 20% 20% Spinal Manipulations In- and out-of-network Durable Medical Equipment and Prosthetic Devices 0% In-network deductible applies 20% In-network deductible applies 0% 50% * 20% 50% * Eye Exams 0% 50% * 20% 50% * Value-Based Drugs 0% 50% * 10% 50% * Prescription Drugs -- Tier 1 0% 50% * 20% 50% * Prescription Drugs -- Tier 2 0% 50% * 20% 50% * Prescription Drugs -- Tier 3 0% 50% * 20% 50% * Specialty Prescription Drugs 0% 50% * 20% 50% * Preauthorization required Specialty Prescription Drugs N/A N/A N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 36

Plan Design QHDHP 2500 100/50 - Aggregate or Embedded Deductible QHDHP 2500 80/60 - Aggregate or Embedded Deductible Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 50% 80% 60% Plan Year Deductible Single: $2,500 Family: $5,000 Plan Year Out-of-Pocket Maximum Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Single: $2,500 Family: $5,000 $0 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 Single: $2,500 Family: $5,000 Single: $5,000 Family: $10,000 $5,000,000 $5,000,000 50% $0 copayment Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 40% Primary Care Office Visit 0% 50% 20% 40% Specialist Office Visit 0% 50% 20% 40% Routine Prenatal Care 0% 50% 20% 40% Outpatient and Diagnostic 0% 50% 20% 40% Testing X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 0% 50% 20% 40% Inpatient Hospitalization 0% 50% 20% 40% Including Maternity Care Emergency Department Visits 0% 0% 20% 20% Emergency Department Transportation 0% 0% 20% 20% Spinal Manipulations In- and out-of-network Durable Medical Equipment and Prosthetic Devices 0% In-network deductible applies 20% In-network deductible applies 0% 50% * 20% 50% * Eye Exams 0% 50% * 20% 50% * Value-Based Drugs 0% 50% * 10% 50% * Prescription Drugs -- Tier 1 0% 50% * 20% 50% * Prescription Drugs -- Tier 2 0% 50% * 20% 50% * Prescription Drugs -- Tier 3 0% 50% * 20% 50% * Specialty Prescription Drugs 0% 50% * 20% 50% * Preauthorization required Specialty Prescription Drugs N/A N/A N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 37

Plan Design QHDHP 3000 100/50 - Aggregate or Embedded Deductible QHDHP 3000 80/60 - Aggregate or Embedded Deductible Member Benefits In-Network Out-of-Network In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 50% 80% 60% Plan Year Deductible Single: $3,000 Family: $6,000 Plan Year Out-of-Pocket Maximum Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Single: $3,000 Family: $6,000 $0 copayment Single: $6,000 Family: $12,000 Single: $10,000 Family: $20,000 Single: $3,000 Family: $6,000 Single: $5,500 Family: $11,000 $5,000,000 $5,000,000 50% $0 copayment Single: $6,000 Family: $12,000 Single: $11,000 Family: $22,000 40% Primary Care Office Visit 0% 50% 20% 40% Specialist Office Visit 0% 50% 20% 40% Routine Prenatal Care 0% 50% 20% 40% Outpatient and Diagnostic 0% 50% 20% 40% Testing X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 0% 50% 20% 40% Inpatient Hospitalization 0% 50% 20% 40% Including Maternity Care Emergency Department Visits 0% 0% 20% 20% Emergency Department Transportation 0% 0% 20% 20% Spinal Manipulations In- and out-of-network Durable Medical Equipment and Prosthetic Devices 0% In-network deductible applies 20% In-network deductible applies 0% 50% * 20% 50% * Eye Exams 0% 50% * 20% 50% * Value-Based Drugs 0% 50% * 10% 50% * Prescription Drugs -- Tier 1 0% 50% * 20% 50% * Prescription Drugs -- Tier 2 0% 50% * 20% 50% * Prescription Drugs -- Tier 3 0% 50% * 20% 50% * Specialty Prescription Drugs 0% 50% * 20% 50% * Preauthorization required Specialty Prescription Drugs N/A N/A N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 38

Plan Design QHDHP 5000 100/50 - Aggregate or Embedded Deductible Member Benefits In-Network Out-of-Network Plan Pays After applicable member copayment, deductible and/or 100% 50% Plan Year Deductible Single: $5,000 Family: $10,000 Plan Year Out-of-Pocket Maximum Includes deductible expenses Lifetime Maximum Benefit In- and out-of-network combined Be Well: Preventive Services Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/ frequency schedules. Single: $5,000 Family: $10,000 $0 copayment Single: $10,000 Family: $20,000 Single: $15,000 Family: $30,000 $5,000,000 50% Primary Care Office Visit 0% 50% Specialist Office Visit 0% 50% Routine Prenatal Care 0% 50% Outpatient and Diagnostic 0% 50% Testing X-ray, lab, MRI, CT scan, etc. Outpatient Surgery/Procedures 0% 50% Inpatient Hospitalization 0% 50% Including Maternity Care Emergency Department Visits 0% 0% Emergency Department Transportation 0% 0% Spinal Manipulations In- and out-of-network Durable Medical Equipment and Prosthetic Devices 0% In-network deductible applies 0% 50% * Eye Exams 0% 50% * Value-Based Drugs 0% 50% * Prescription Drugs -- Tier 1 0% 50% * Prescription Drugs -- Tier 2 0% 50% * Prescription Drugs -- Tier 3 0% 50% * Specialty Prescription Drugs 0% 50% * Preauthorization required Specialty Prescription Drugs N/A N/A *Copayments and payments for these services do not to the plan year out-of-pocket maximum. This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to the Health Alliance Policy for detailed information regarding these plans. 39