HOME BANK - S2395 NON-GRANDFATHERED CONSUMER DRIVEN HEALTH PLAN BENEFIT SHEET

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1 CONSUMER DRIVEN HEALTH PLAN BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to days from incurred Filing Limit date, except when 180 days would extend past 90 days beyond the plan year Mailing Address & PPO Company. PPO Co.: PPO CIGNA Physicians & Hospitals PPO & NonPPO: Mail claims to Cigna, P.O. Box , Chattanooga, TN Electronic Payer ID Certain Cigna Ancillary Providers are required to file claims to the Ancillary Vendor Network If members access a Third Party Network will have remit info as follows (and reflected on ID cards): Community Health Network Cigna Mt-CHN P.O. Box 3018 Missoula, MT EDI# Mississippi Health Partners MHP Systems P.O. Box Jackson, MS EDI# Don t forget to get a copy of the Patient s ID Card for claim filing directions in order to expedite claims processing Pre-Existing Does not apply Utilization Review: CIGNA PPO Members CIGNA Must precertify services listed. Emergency admissions within 48 hours or 1 st business day. List services here Inpatient confinements; Maternity admission with a length of stay greater than 48 hours for a vaginal delivery or 96 hours for a cesarean delivery, Organ Transplants, Penalty: Inpatient Confinements: Room & Board reduced to 70% for PPO and 50% for NonPPO The Employer maintains an Organ & Tissue Transplant Policy separate and apart from this Plan. Providers and members must call directly for precertification of all services including evaluation and consult. Utilization and Precertification is intended to verify the Medical Necessity and medical appropriateness of care and does not guarantee or eligibility under the Plan. The expenses will be subject to all other provisions of the Plan Document. GILSBARDM-# v1-CDHP_eff_1_1_2017_-_present Page 1 of 6

2 ANNUAL MAXIMUM BENEFIT Unlimited DEDUCTIBLE, PER CALENDAR YEAR Expenses applied toward the satisfaction of the PPO amount will not be applied toward satisfaction of the Non- PPO, and expenses applied toward the satisfaction of the Non-PPO amount will not be applied toward satisfaction of the PPO. Per Participant $2,000 $4,000 Per Family $4,000 $8,000 Please Note: If you receive services from a Non-PPO Provider, the lower percentage paid by the Plan will be based on Reasonable and Customary charges as determined by the Plan. The Non-PPO Provider may bill you for the difference between their actual charges and the amount determined by the Plan to be Reasonable and Customary. Any amount billed above Reasonable and Customary charges will not be considered covered charges and will not count towards your Calendar Year Deductible or Maximum Out-of-Pocket expenses. MAXIMUM MEDICAL OUT-OF-POCKET EXPENSES, PER CALENDAR YEAR Expenses applied toward the satisfaction of the PPO out-of-pocket amount will not be applied toward satisfaction of the Non-PPO out-of-pocket, and expenses applied toward the satisfaction of the Non-PPO out-of-pocket amount will not be applied toward satisfaction of the PPO out-of-pocket. Per Participant $6,000 $12,000 Per Family $12,000 $24,000 NOTE: The following charges do not apply toward the out-of-pocket expense amount and are never paid at 100%: Prescription Drug Card Copayments & Expenses Non-covered charges, regardless of whether or not they are Incurred at a PPO or Non-PPO provider HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Acupuncture Ambulance Bariatric Surgery Limited to $1,000 calendar year maximum, combined with obesity Behavioral/Mental Health and Substance Use Disorders Inpatient Includes Residential Treatment Behavioral/Mental Health and Substance Use Disorders Outpatient Includes Partial Hospitalization Blood Blood and blood derivatives that are not donated or replaced are covered. Breast Reduction (not in connection with a mastectomy) Subject to Medical Necessity Chemotherapy & Radiation Therapy Clinical Trials (as defined by this Plan for cancer or other life-threatening diseases or conditions) Includes coverage for routine patient costs associated with participation in approved Clinical Trials only. If one or more PPO providers are participating in a Clinical Trial, the Plan may require that the qualified individual participate in the Clinical Trial with the PPO provider. The Plan will cover Non-PPO providers outside the state in which the qualified individual resides only if there is not a PPO provider conducting the same trial in state. Chiropractic Treatment Dental Impacted Wisdom Teeth Non-Surgical Treatment of the Spine Covered under Dental plan Covered under Dental GILSBARDM-# v1-CDHP_eff_1_1_2017_-_present Page 2 of 6

3 Diabetes Monitoring Plan (Diabetes testing supplies through the Preferred Diabetes Monitoring Plan) 100%, no The Employer maintains a Preferred Diabetes Monitoring Plan through the ActiveCare Diabetes Wellness Program. Only Participants enrolled in the Preferred Diabetes Monitoring Plan will receive items such as a glucometer, testing strips, control solution, lancets, and a lancing device at the listed benefit percentage. See your Employer for more details on participation in the Preferred Diabetes Monitoring Plan and receiving these diabetes testing supplies. Diagnostic Testing (Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Diagnostic Testing (X-ray, lab) Inpatient Diagnostic Testing (X-ray, lab) Outpatient Hospital Diagnostic Testing (X-ray, lab) Stand Alone Facility Diagnostic Testing (X-ray, lab) Office Durable Medical Equipment Emergency Services in an Emergency Room Copay waived if admitted directly to Hospital from Emergency room Extended Care/Skilled Nursing Facility Foot Conditions Physicians' services in connection with corns, calluses or toenails are excluded, unless the charges are for the partial or complete removal of the nail roots. Routine foot care and foot orthotics are not covered Gastric Bypass Hearing Aids Hearing Screening Home Health Care Hospice Care Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Hospital / Facility Inpatient (Precertification Required) Room and Board is limited to the semi-private room rate, or if the Hospital has private rooms only, 90% of the lowest private room rate. ICU as billed. Hospital / Facility Outpatient Infertility/Sterility ($1,000 Lifetime maximum) Excludes fertility drugs and artificial fertilization. $100 copay, then $100 copay, then Bariatric Surgery GILSBARDM-# v1-CDHP_eff_1_1_2017_-_present Page 3 of 6

4 Maternity Maternity-related expenses for a dependent Child are not covered except as required by law for prenatal care. Prenatal care as required by federal law. Preventive Care Preventive Care Other eligible charges, As required by Federal Law, this benefit includes coverage for the first 48 hours of maternity following a vaginal delivery and the first 96 hours following a cesarean section. Precertification is not required; however, it is still encouraged. Notification is required for any stay that is in excess of this minimum length of stay. If not precertified, penalties may apply. See Utilization Review for full details. Newborn Care (routine inpatient) Non-Surgical Treatment of the Spine ($1,500 Calendar Year maximum) (OV & X-ray included in the Calendar Year maximum) Obesity Limited to $1,000 Calendar year maximum, combined with Bariatric Surgery Organ Transplants The Employer maintains an Organ & Tissue Transplant Policy separate and apart from this Plan. Providers and members must call directly for precertification of all services including evaluation and consult. ($25,000 Lifetime maximum for donor charges) Provider should notify Customer Contact Center prior to starting any transplant services, including initial evaluation. Case Management is strongly suggested. Refer to plan document for further limitations & exclusions. Orthotics / Prosthetics Physician Services- Inpatient Visits Physician Services- Inpatient Surgeon Physician Services- Outpatient Visits (services other than in a Physician's office) Physician Services- Outpatient Surgeon (services other than in a Physician's office) Physician Services- Office Visits Physician Services- In-office Surgeon Prescription Drugs Inpatient Prescription Drugs Outpatient Hospital / Facility Inpatient Prescription Drug Benefits schedule and section Preventive Care Benefit Preventive services are covered as required by the Patient Protection and Affordable Care Act, as recommended by the United States Preventive Services Task Force (USPSTF) and immunizations will be covered as recommended by the Centers for Disease Control (CDC). All services are limited to no more than once annually or as recommended by the USPSTF. Breast pumps are limited to one per calendar year 100%, no GILSBARDM-# v1-CDHP_eff_1_1_2017_-_present Page 4 of 6

5 Private Duty Nursing (Limited to Outpatient only) Rehabilitation Services (Cardiac Rehab, Occupational, Physical, Speech and Vision Therapies) Provider must send letter of medical necessity and all applicable notes. Cardiac rehab therapies limited to phase I & II Speech Therapy limited to 20 visits Calendar Year maximum (Additional visits may be covered if approved by Case Management) Vision Therapy limited to $3,500 Lifetime Maximum Sleep Disorder Covered only if medically necessary. Sleep Study Other eligible charges Sterilization applicable service for applicable service for Vasectomy Female Sterilization as required by federal law Temporomandibular Joint Syndrome Urgent Care Facility (includes all covered charges billed by facility) Vision Screening, unless otherwise stated Wig After Chemotherapy Limited to one lifetime Preventive Care Preventive Care GILSBARDM-# v1-CDHP_eff_1_1_2017_-_present Page 5 of 6

6 PRESCRIPTION DRUG CARD OPTION Express Scripts - Phone No RxBIN: , RxPCN: A4, RxGRP: ACJA Non-Express Scripts Prescription Drug Out of Pocket Maximum Per Participant $1,150 Per Family $2,300 Prescription Drug Card Options Copayment Benefit Percentage Retail Pharmacy Option (30-day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. $0 100% Generic drug $15 100% Preferred Brand Name drug $35 100% Non-Preferred Brand Name drug $75 100% Specialty drugs (high dollar or injectable drugs) First fill allowed at Retail Pharmacy, the Cura Script must be utilized Mail Order Option (90-day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. $ % $0 100% Generic drug $30 100% Preferred Brand Name drug $70 100% Non-Preferred Brand Name drug $ % GILSBARDM-# v1-CDHP_eff_1_1_2017_-_present Page 6 of 6