Life Insurance — Active participant

$20,000

Accidental Death/Dismemberment Insurance — Active participant under age 70 only

$20,000

In-Network

Out-of-Network

Plan payment percentage for covered preventive services
(See list of preventive services starting on page 56.)

100%

70% after deductible

Deductible per calendar year

Per person

$400

Per family

$800

Utilization review noncompliance penalty
(Inpatient confinements, including residential treatment facilities
and skilled nursing facilities, and outpatient or inpatient surgery)

$100

In-Network

Out-of-Network

Plan payment percentages

90%

70%

Out-of-pocket limits

Per person

$2,500

$5,000

Per family

$5,000

$10,000

(In- out-of-network limits must be met separately.)

Chiropractic care

$1,000 per calendar year

Congenitally missing teeth - maximum benefit for treatment and/or replacement of congenitally missing teeth

$5,000 per lifetime

Emergency room (waived if visit meets definition of an "emergency," or if admitted)

$200 deductible per occurrence; calendar year deductible and
coinsurance also apply

Foot orthotics

2 pairs every 3 calendar years

Home health care

100 visits per calendar year

Hospice care

180 days per lifetime

Absolute Solutions

Blue Cross Blue Shield

Out-of-Network

Imaging (MRIs, CT scans, PET scans)

100%

90%

70%

no deductible

after deductible

Infertility treatment - Maximum benefit for participant and spouse (only)

$10,000 per lifetime

Obesity (non-surgical treatment) - participant & spouse (only)

$1,000 per lifetime

Office visit with in-network (PPO) physician
(Deductible does not apply. Co-pay applies only to the charge for the visit itself. All other services subject to deductible and
coinsurance.)

100% after $25 copay

Out-of-network (non-PPO) surgical center

not covered

Partial inpatient/intensive outpatient treatment for substance abuse and mental/nervous disorders
(Additional visits may be covered if pre-certified by the review
organization.)

12 visits for all related conditions

Physical/occupational therapy
Additional visits may be covered if pre-certified by the review
organization. Physical therapy performed at Union Wellness Centers is not subject to visit limits or copays.

12 visits for all related conditions and
$50 per visit copay

Refractive surgery such as Lasik

excluded

Residential treatment facility

45 days for all related confinements
Annually

Skilled nursing facility

45 days for all related confinements Annually

Speech therapy for children under age 12

40 visits per calendar year

Participant Pays

30-day retail

Generic drugs

The lesser of 20% or $5

Preferred brands

20%

Non-preferred brands

20%

90-day retail

Generic drugs

The lesser of 20% or $15

Preferred brands

20%

Non-preferred brands

20%

Mail-order

Generic drugs

The lesser of 20% or $10

Preferred brands

20%

Non-preferred brands

20%

For Retail, Mail Order & Specialty

• Use of 30-day retail is mandatory for first two fills of a long-term or maintenance medication.
• Mail-order or 90-day retail is mandatory for the 4th and all subsequent refills.
• Patients will pay the difference in cost plus non-preferred brand co-pay if generic substitution is declined.
• Additional requirements apply — see "Clinical Management Programs" starting on page 61.

Participant Co-Pay Limit

Out-of-pocket limit for prescription drug co-pays per calendar
year

$4,600 per person
$9,200 per family

Maximum benefit

Per person

$1,250 per calendar year

Annual maximum waived for preventive and routine services (those paid at 100%) for children under age 19.

Plan payment percentages

Preventive and routine

100%

Minor restorative

80%

Major restorative

50%

Orthodontia (for children age 18 and under only)

Plan payment percentage

50%

Maximum benefit

applies to $750 annual maximum
shown above

VISION BENEFIT

NVA Network

Out-of-Network

Eye exam, one per calendar year

Provided in full

$35

Eyeglass lenses, one pair per year

Provided in full (plastic lenses)

Single vision, per pair

$50

Bifocal, trifocal or progressive lenses, per pair

$65

Frame, one every two calendar years

$50 wholesale allowance

$35

Contact lenses in lieu of eyeglasses, per calendar year

$100 allowance

$90

Safety glasses for active participants only, one per year

$100 allowance

$100

Exam

$75 every two calendar years

Hearing aid device (per ear)

$750 every three calendar years