Copay Plans -- Benefit Highlights

3

This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for

reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary

limits unless you use a network. We recommend review of the more detailed plan information on pages 9-13.

Copay Select

SM

Copay Saver

SM

Design Basics

Network Type

Preferred Network Included

Calendar-Year Deductible Choices

$500, $1,000, $1,500, $2,500

$2,500

(maximum 2 per family, per calendar year)

Coinsurance

80/20 to $10,000

80/20 to $15,000

(per covered person, per calendar year)

then 100%

then 100%

Lifetime Maximum Benefit

$3 million

$3 million

(per covered person)

Initial Rate Guarantee

12 months

12 months

(subject to benefit and address changes)

Coverage percentages below are effective AFTER deductibles have been met unless otherwise indicated.

Inpatient Expense Benefits

Room and Board, Intensive Care Unit,

80%

80%

Operating Room, Recovery Room,

and Professional Fees of Doctors,

Surgeons, Nurses

Other Covered Inpatient Services

80%

80%

Outpatient Expense Benefits

Surgeon, Assistant Surgeon,

80%

80%

and Facility Fees

Hemodialysis, Radiation,

80%

80%

Chemotherapy, and Organ

Transplant Drugs

CAT Scans, MRIs

80%

80%

Outpatient X-ray and Lab

80%

80% if performed within 14 days

(performed in the doctor’s office or elsewhere)

of surgery or confinement

Emergency Room Fees

80% -- additional $100 Copay

80% -- additional

for illness if not admitted

$500 Copay if not admitted

Other Covered Outpatient Expenses

80%

See page 10

Routine Health Benefits

Doctor Office Visit

For history and exam: $35 Copay, then 100%

(maximum 2 visits per person, per year)

Other services: Not Covered

Mammography, Pap Smear,

80%

and PSA Testing

Adult Preventive Care

(age 19 or older)

Not Covered

Well Child Care/Immunizations

Not Covered

(ages 0-18)

Outpatient Prescription Drugs

Generic: $15 Copay

Generic: $15 Copay

Name-Brand: $100 calendar year

Name-Brand: Not Covered

deductible -- then $30 Copay for preferred,

$60 Copay for non-preferred

(Name-Brand reimbursed at

Generic price if Generic is available)

Optional Benefits

For a complete list, see page 8.

For history and exam:

$25 Copay, then 100%

For other services,

including X-ray and Lab:

80% after deductible