2013 Benefits Retiree under 65 UNITED HEALTHCARE PPO BLUE CROSS/BLUE SHIELD PPO AETNA HMO Open Access National Plans Group # 195643 Group #13570-00 Group # 813972 Single: $601.01 Two Person: $1,202.03 Family: $1,803.04 Single: $510.19 Two Person: $1,020.38 Family: $1,530.57 Single, $1,500; family $3,000; Pharmacy, $2,500/person Single, $1,250; family $2,500; Pharmacy, $2,500/person None None Retiree Monthly Rates BENEFITS Annual out-of-pocket limit Lifetime maximum Out of network option Fitness Center HOSPITAL / Inpatient Care Hospital care (semi-private room), surgery, x-rays and lab Skilled Nursing Facility Single: $467.46 Two Person: $934.91 Family: $1,402.37 Single, $1,500; family $3,000; including copayments; Pharmacy, $2,500/person None None None Annual deductible: single, $500; Annual deductible: single, $500; None family $1,500; Then 70% family $1,500; Then 70%, then coverage to out-of-pocket limit 100% coverage to out-of-pocket ($3,000/$6,000) limit ($2,500/$5,000) GlobalFit Discount Program $250 copay per admission, then $250 copay per admission, then 85% coverage 90% coverage 85% coverage, up to 120 days 90% coverage per confinement $250 copay per admission, then 100% coverage 100% coverage, up to 120 days per calendar year $25 copay, then 85% coverage $30 copay, then 100% coverage $25 copay, then 100% coverage $100 copay, then 85% coverage; copay waived if admitted 85% coverage $100 copay, then 90% coverage; copay waived if admitted 90% coverage $100 copay, then 100% coverage; copay waived if admitted 100% coverage URGENT CARE EMERGENCY CARE Emergency Room Emergency transportation 2013 Benefits Retiree under 65 OUTPATIENT CARE Office visit UNITED HEALTHCARE PPO BLUE CROSS/BLUE SHIELD PPO AETNA HMO Open Access $25 copay, PCP; $35 copay, $20 copay, PCP; $30 copay, $25 copay, PCP; $35 copay, specialist, then 100% coverage specialist, then 100% coverage specialist, then 100% coverage Injections $7 copay, then 100% coverage 90% coverage $25 copay, PCP; $35 copay, specialist, then 100% coverage. No serum copay Preventive care (Care covered $25 copay, PCP; $35 copay, $20 copay, PCP; $30 copay, $25 copay, PCP; $35 copay, under the Affordable Care Act is specialist, then 100% coverage specialist, then 100% coverage specialist, then 100% coverage reimbursed at 100% with no copay) Inpatient maternity care (Routine $250 copay per admission, then $250 copay per admission, then $250 copay per admission, then 85% coverage 90% coverage 100% coverage prenatal care under the Affordable Care Act is covered at 100% with no copay) Pediatric care (Care covered under the Affordable Care Act is reimbursed at 100% with no copay) Gynecological care (Care covered under the Affordable Care Act is reimbursed at 100% with no copay) X-ray, lab and diagnostic testing $25 copay, then 100% coverage $20 copay, then 100% coverage $25 copay, then 100% coverage $25 copay, then 100% coverage $20 copay, then 100% coverage $25 copay, then 100% coverage Included in copay if performed 90% coverage for all diagnostic $35 copay, then 100% coverage in a physician's office, otherwise lab and x-ray for lab and x-rays performed in 85% coverage outpatient facility. Office copay applies to diagnostic testing performed in a physician's office. 2013 Benefits UNITED HEALTHCARE PPO BLUE CROSS/BLUE SHIELD PPO $30 copay, then 100% coverage $250 copay per admission, then 90% coverage 90% coverage $35 copay, then 100% coverage Outpatient short-term speech, physical, occupational and respiratory therapy $35 copay, then 100% coverage $250 copay per admission, then 85% coverage $35 copay, then 100% coverage; 100% coverage if provided in office without other services $35 copay, then 100% coverage; limited to 20 visits per calendar year $30 copay, then 100% coverage; limited to 30 visits per calendar year $35 copay, then 100% coverage; limited to 60 visits per year; 100% coverage, outpatient hospital Medical supplies Prosthetics Durable medical 85% coverage 85% coverage 90% coverage 90% coverage 100% coverage 100% coverage, limited to $10,000 per calendar year Retiree under 65 OTHER BENEFITS Mental health/Substance use disorder Outpatient Inpatient Cancer care (radiation therapy and chemotherapy) Prescriptions AETNA HMO Open Access $250 copay per admission, then 100% coverage $35 copay then 100% coverage; 100% coverage, outpatient hospital Retail - 30-day Supply: Generic - $7 copay Formulary - 20% (Min $25; Max $75) Non-Formulary - 50% (Min $50; Max $100) Mail Order - 90-day Supply: Generic - $17.50 Formulary - 20% ($62.50; $187.50) Non-Formulary - 50% ($125; $250) Administered through ExpressScripts (https://www.express-scripts.com) 2013 Benefits Retiree under 65 UNITED HEALTHCARE PPO BLUE CROSS/BLUE SHIELD PPO Vision Routine exam Not covered Not covered Materials Not covered Not covered Hearing (Care covered under the Affordable Care Act is reimbursed at 100% with no copay) Routine exam Not covered Not covered Materials Chiropractic Not covered $35 copay, then 100% coverage; $1,500 limit Not covered $25 copay, then 100% coverage; limited to 20 visits per calendar year Website/Provider directory https://www.myuhc.com www.mybenefitshome.com AETNA HMO Open Access $35 copay, then 100% coverage; 1 routine eye exam every 24 months Discounts available through EyeMed Discount Program $35 copay, then 100% coverage; 1 routine hearing exam every 24 months Not covered $35 copay, then 100% coverage http://www.aetna.com/docfind/ Product name Choice Plus BCBS PPO Aetna Select (SM) Open Access The above contains a brief overview of the various benefit programs and does not describe any plan, its provisions or limitations in any detail. Please refer to the benefit plan booklet for more information.