Hours Paid Per Month

Plan Features Class I Class II Class in 131 or

1-90 91-130 more
Medical Outpatient
Physician Office Visit *
Per Visit Benefit Annual $65 $75 $100
Number of Vis its 10 10 10

X-Ray / Lab Benefit ** $250 $250 $250

Per Visit Benefit Annual
Number of Vis its 10 10 10

Prescription Drug Benefit $55 $70 $80

Per Prescription Benefit Annual Number
of Prescriptions Oral Contraceptives 16 18 20
Prescription Discount Included Included Included
Included Included Included
Outpatient Surgical Facility Benefit
Benefit per Surgical Occurrence for Facility Only
$1,250 $1,250 $1,750

Medical Inpatient
Hospital Room and Board & Miscellaneous
Hospital Benefit
Daily Benefit (up to 45 days per confinement) $1,000 $1,500 $2,250 $1,750

ICU & Coronary Care

Daily Benefit (up to 45 days per confinement) $1,500 $2,625
$250
Inpatient Routine
Newborn Nursery Care Benefit
Daily Benefit (up to 45 days per confinement) $250 $250

Medical Outpatient and Inpatient $1,375

Surgical Benefit
Benefit per Surgical Procedure $1,200 $ 2 7 5 $1,350 $1,750

Anesthesia Benefit +
Benefit per Surgical Procedure $240 $350

Accident Benefit + $1,130 $1,575

* Routine preventive officevisit and immunizations for dependents under 18 years old are coveredunder the physician office visit benefit.
** Routine diagnostichealth screenings are coveredunder the X-Ray / Lab Benefit.
+ Multiple surgical CPT codes billed in the course of a single clinical encounter or visit are to be adjudicated andpaidas oneSurgical Procedure.

J
~ aag 10
 Hours Paid Per Month

Class I 1-90 Class II 91-130 Class ffl 131 or more

Ancillary Benefits Included

Vision Benefits
Vision Emm (every 12 months) Single $55 $65 $85
Lenses (every 24 months) Contact $65 $75 $95
Lenses (every 24 months) Bi-focal $65 $75 $95
Lenses (every 24 months) Frames (every $90 $100 $120
24 months) $90 $100 $120

Dental Benefits
Employee Annual Maximum Dependent $1,050 $1,250 $1,500
Annual Maximum Annual Deductible per $525 $625 $750
Covered Person Preventive, Diagnostic $25 $25 $25
and Routine Restorative Care Pays Major 80% up to the 80% up to the 80% up to the
Restorative Care Pays* Annual Maximum Annual Maximum Annual Maximum
50% up to the 50% up to the 50% up to the
Annual Maximum Annual Maximum Annual Maximum

Life and AD&D Benefits

Employee $5,000 $7,500 $10,000
Spouse $2,500 $3,750 $5,000
Child (+6 months) $2,500 $3,750 $5,000
Child (14 days to 6 months) $400 $400 $400
Accidental Death & Dismemberment $5,000 $7,500 $10,000
(Employee Only)

Disability Benefits - Employee Only

Maximum Weekly Benefit (Up to 26 weeks) $75 $95 $105
(Benefits begin on <§' day)

Informed Health Line and Discount Included Included Included

Programs and Services

Major Restorative Care Expenses will be paid after the covered person has been continuously insured by a Plan for at least 12
consecutive months. (If the Plan replaces another group dental plan, the covered person will be given credit for the period of
time they were covered under such other plan afterproof of credible coverage is provided.)