MERCY MEDICAL CENTER - DUBUQUE TRADITIONAL PPO PLAN $10/20%/40% RX PROVIDED BY PREFERRED HEALTH CHOICES EFFECTIVE JANUARY 1, 2015

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MERCY MEDICAL CENTER - DUBUQUE TRADITIONAL PPO PLAN $10/20%/40% RX PROVIDED BY PREFERRED HEALTH CHOICES EFFECTIVE JANUARY 1, 2015 DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS facilities and

1 MERCY MEDICAL CENTER - DUBUQUE TRADITIONAL PPO PLAN $10/20%/40% RX PROVIDED BY PREFERRED HEALTH CHOICES EFFECTIVE JANUARY 1, 2015 DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS facilities and Aligned Deductible - per calendar year* $250 per member $500 per family $750 per member $1,500 per family $1,500 per member $3,000 per family Copays/Coinsurance Fixed Dollar Copays $20 Office visits $30 Specialist office visits Outpatient mental health care visits $35 Urgent care visits $100 Emergency room visits $50 Outpatient surgery facility fee only $30 Office visits Outpatient mental health care visits $35 Urgent Care $40 Specialist office visits $100 Emergency room visits Outpatient surgery facility fee only $500 Inpatient admissions $35 Urgent Care $100 Emergency room visits $200 Outpatient surgery facility fee only $1,000 Inpatient admissions Percent Coinsurance 10% 20% 40% of R&C Out-of-Pocket Maximum per calendar year* Includes Prescription drugs,, coinsurance and s $2,500 per member $5,000 per family Lifetime Maximum Includes Prescription Drugs * FULL INTEGRATION (DOLLARS ACCUMULATE TOWARDS ALL TIERS) $4,750 per member $9,500 per family None $9,500 per member $19,000 per family FACILITY OUTPATIENT DIAGNOSTIC SERVICES facilities and Aligned MRI, MRA, PET and CAT Scans and Nuclear Medicine. Services need to be provided at a CHE Trinity facility to be paid as Tier 1. Other Diagnostic Tests, X-rays, Laboratory & Pathology. Services need to be provided at a CHE Trinity facility to be paid as Tier 1. Radiation Therapy

2 EMERGENCY MEDICAL CARE facilities and Aligned Hospital Emergency Room Qualified Medical Emergency & First Aid Services after $100 ; waived if admitted after $100 ; waived if admitted of R&C after $100 ; waived if admitted Non-Emergency use of the Emergency Room (Please note: applies only to non-emergency use of the emergency room) Covered - $100, then 90% after Covered $100, then 80% after Facility Based Urgent Care Centers after $35 after $35 Ambulance Services medically Covered 90% after necessary transport after $35 Covered 80% of R&C after INPATIENT HOSPITAL CARE facilities and Aligned Semi-Private Room, General Nursing Care, Hospital Services and Supplies Covered - 90% after Covered - $500 per confinement, then 80% after Unlimited days Covered $1,000 per confinement, then 60% of R&C after ALTERNATIVES TO INPATIENT HOSPITAL CARE facilities and Aligned Skilled Nursing Facility Covered $500, then 80% after 120 days per calendar years Hospice Care waived waived Unlimited days Home Health Care 120 visits per calendar year Covered $1,000, then 60% of R&C after OUTPATIENT SURGICAL SERVICES (FACILITY FEE) facilities and Aligned Surgery includes related surgical services Covered $50, then 90% Covered $100, then 80% after Covered $200, then 60% of R&C after

3 OUTPATIENT THERAPY facilities and Aligned Outpatient Physical, Speech and Occupational Therapy. Services need to be provided at a CHE Trinity facility to be paid as Tier 1. Limited to 60 visits each type of therapy per calendar year. Services are covered when performed in the outpatient department of the hospital, or approved freestanding facility. Cardiac Rehabilitation Maximum of 36 visits in a 12 week period Chemotherapy HUMAN ORGAN TRANSPLANTS Specified Organ Transplants (Utilization of a designated transplant network is required) No coverage for services rendered at a non-ioe Transplant facility INPATIENT MENTAL HEALTH CARE AND SUBSTANCE ABUSE TREATMENT Inpatient Mental Health and Substance Abuse Care * Covered $1,000, then 60% of R&C after * DEDUCTIBLE OTHER SERVICES Durable Medical Equipment/Medical Supplies Prosthetic and Orthotic Appliances Private Duty Nursing after after after

4 PREVENTIVE SERVICES AS PER HEALTH CARE REFORM, PREVENTIVE SERVICES AS DEFINED BY THE U.S. PREVENTIVE SERVICES TASK FORCE PERFORMED BY AN IN-NETWORK PROVIDER WILL BE AT NO COST TO THE ASSOCIATE Health Maintenance Exam age 18 and over; includes related chest X-rays, EKG, and lab procedures performed as part of the exam waived Health Maintenance Exam age 18 and over; waived Annual Gynecological Exam - one per calendar year waived Pap Smear and related lab fees one per calendar year waived Mammography Screening One baseline for ages 35-39, then waived one annual mammogram age 40 and over Prostate Specific Antigen (PSA) and DRE-One Screening - one per calendar year for males 40 and over waived Colonoscopy Screening Exam one every 10 years after age 50 waived Sigmoidoscopy Screening Exam one per calendar year age 40 and over waived Well-Baby and Child Care through age 17 7 exams in the first 12 months of life waived 3 visits in the second 12 months of life 3 visits in the third 12 months of life 1 exam per year thereafter Immunizations - pediatric and adult waived waived waived waived waived waived waived waived waived waived waived after after after after after after after after after after PHYSICIAN OFFICE SERVICES Office Visits Includes: Primary care and specialist physicians Presurgical consultations Initial visit to determine pregnancy Covered 100% after PCP $20 - Specialist $30. One applies to the office visit exam and all services performed during the office visit (e.g., lab, x-ray, etc.) Covered 100% after PCP $30 - Specialist $40. One applies to the office visit exam and all services performed during the office visit (e.g., lab, x- ray, etc.) after PROFESSIONAL DIAGNOSTIC SERVICES MRI, MRA, PET and CAT Scans and Nuclear Medicine. Services need to be provided at a CHE Trinity facility to be paid as Tier 1. Other Diagnostic Tests, X-rays, Laboratory & Pathology. Services need to be provided at a CHE Trinity facility to be paid as Tier 1. Radiation Therapy after after after

5 MATERNITY SERVICES Pre-Natal and Post-Natal Care waived Delivery and Nursery Care waived OUTPATIENT MENTAL HEALTH CARE AND SUBSTANCE ABUSE TREATMENT Outpatient Mental Health Care Covered- 100% after $30 Outpatient Substance Abuse Care Covered- 100% after $30 OTHER PROFESSIONAL SERVICE Covered- 100% after $30 Covered- 100% after $30 Inpatient Medical Care (Physician visits) Allergy Testing and Therapy Injections Chiropractic Care (20 visits per calendar year) Physical Therapy -Independent Physical Therapist (Limited to 60 visits per calendar year combined with outpatient physical therapy). Services need to be provided at a CHE Trinity facility to be paid as Tier 1. OTHER MISC SERVICES Non Surgical Weight Management Program of billed eligible expenses up to $500 DISEASE MANAGEMENT PROGRAMS: DIABETES AND HYPERTENSION (HIGH BLOOD PRESSURE) You, and/or your covered spouse (ages 18-85) can get solid support managing your condition with the Disease Management Program. This program is designed to help you control your condition in ways that work for you. Your participation includes the following: Work with a nurse to help you feel as healthy as possible and keep you informed. Newsletters containing updates to the program, current medical information about diabetes and hypertension and tips for healthy living. Educational materials to help you manage and control symptoms. Courtesy letters to remind you of important exams. Interact with the disease management staff, in person, by or by phone

6 To qualify for a $50 Visa gift care incentive*, you must confirm your participation by contacting our dedicated disease management nurse at , toll-free or creinert@mahealthcare.com. After you qualify for the incentive, your gift card will automatically be sent to you at the beginning of the following quarter. *Please note that gift card incentives are considered taxable income. HEALTHY BEGINNINGS MATERNITY PROGRAM There s a lot of information on pregnancy. Using the Healthy Beginnings program will make it easier for you (or your enrolled spouse) to find the information you need, by sharing materials to help you throughout your pregnancy and even after your baby is born. If you begin your prenatal care by having your first prenatal visit by the 16th week of pregnancy, participants will receive, a $50 gift card upon completion of the post-partum home visit.* The home visit is scheduled prior to you leaving the hospital and occurs typically within hours after discharge. Your gift card will be automatically sent to you at the beginning of the quarter following the birth of your baby. It s easy to qualify for the program: 1. Just begin receiving your prenatal care by the 16 week of your pregnancy and participate in the postpartum home visit once your baby is born. You are automatically enrolled. However, if you have questions, you may call or toll-free at from 8 a.m.to 5p.m. 2. After you qualify for the incentive, your gift card will automatically be sent to you at the beginning of the following quarter. *Please note that gift card incentives are considered taxable income. Important Information: Certification for certain non-preferred must be obtained in order to avoid a reduction in benefits for that care. Certification required for Hospital, Treatment Facility, and Convalescent Facility Admissions. In addition, certification is required for Home Health Care and Hospice Care. Plan limits and maximums are combined for in-network and out-of-network care. This plan does not cover all healthcare expenses and excludes or limits coverage for some medical services. Members should refer to their plan documents to determine which medical services are covered and to what extent. This chart displays only a general description of your benefits. Should there be a conflict between the benefits shown on the chart and those in the legal plan documents, the terms of the plan documents will be used to determine coverage and benefits. Plans are provided by Preferred Health Choices. PRESCRIPTION DRUGS ADMINISTERED BY CVS CAREMARK CVS CAREMARK MEMBER SERVICES Retail 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name Ministry Organization on-site pharmacy 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name Mail Order 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $10 20% with $30 minimum and $80 maximum 40% with $60 minimum and $100 maximum 100% after $30 20% with $90 minimum and $240 maximum 40% with $180 minimum and $300 maximum 100% after $25 20% with $75 minimum and $200 maximum 40% with $150 minimum and $250 maximum If the brand drug has a specific equivalent generic drug available and the plan participant receives the brand, then in addition to the, the plan participant must also pay the difference between the ingredient cost of the brand drug and the generic drug. Note: Infertility drugs are covered at 50% Specialty medications must be filled at a pharmacy or through the CVS Caremark Specialty program; prescriptions limited to a 30 day supply. Mandatory Maintenance is required for each maintenance medication after an initial retail prescription and two refills. Coverage of Preventive Services Medications (under the Patient Protection and Affordable Care Act

7 (No ): Prescription required - Iron supplements (Ages 6 months through 12 months), Oral Fluorides (Ages 6 and younger), Aspirin (ages 45 and older), Folic Acid, Immunizations, Vitamin D (Ages 65+), Bowel Preparation Medications (ages 50 through 74), and Breast Cancer Drugs Prescription required - Tobacco Cessation - Nicotine replacement products, including Nicotine patch, gum & lozenges. Also covers generic Zyban or Chantix Exclusions: Cosmetic medication Anti-wrinkle agents, Hair growth / removal, etc Erectile Dysfunction (ED) Medications Non-Sedating Antihistamine (NSA) Drugs The following is a list of the drugs that need prior authorization to be covered (not intended to be an all-inclusive list): (Your physician must call to obtain approval for a period of up to one year) Singulair Anabolic steroids Topical acne Oral contraceptives Compounds $300 an greater Specialty medications Anti-obesity agents Narcolepsy The following is a list of most but not all of the drugs that have a quantity limit imposed: Flu medication Migraine medication Due to the large number of available medicines, this list is not all inclusive. Please note that this list does not guarantee coverage and is subject to change. Your prescription benefit plan may not cover certain products or categories, regardless of their appearance on this list. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. For a complete description of benefits please see the applicable summary plan descriptions. If there is a discrepancy between this summary and any applicable plan document, the plan document will control. More information is available through Caremark.com to help you manage your prescription drug program. You will be able to locate a pharmacy, order mail service refills, track mail service orders, and ask questions. For additional information contact Caremark at

ESSENTIAL ASSIST PPO PLAN (WITH HRA) $10/25%/50% RX PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2018 AETNA INC.

ESSENTIAL ASSIST PPO PLAN (WITH HRA) $10/25%/50% RX PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2018 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned