Small Group Guide 2019

Transcription

1 AD: After Deductible p/p: Per Person Small Group Guide 2019 This publication is only intended to be used for agent and broker education and must not be distributed or used with the general public.

2 Why Choose Optima Health Table of Contents Getting Started... 4 How We Can Help... 6 Health and Wellness... 8 Plan Overview...10 Plan Details...12 BusinessEDGE...36 Wrapping It Up...47 Virginians 2

3 We make it simple to choose a health plan that is good for employees and for the bottom line. With more than three decades of experience serving residents of the Commonwealth of Virginia, Optima Health knows what s important to employers. Business owners don t have to be experts in insurance or healthcare. It s our job to make it easier for you and for businesses of all sizes to make good health plan decisions. Serving Virginians 2019 SMALL GROUP GUIDE 3

4 Getting Started Together When employees have questions about their plan, our dedicated team is here to help. They can count on having another Virginian answer their call promptly and start helping immediately. Optima Health also offers a userfriendly mobile app and online tools to make it simple and easy for members to get the most out of their health plan on their terms and time schedule. We choose Optima Health because as a non-profit, we often can t always offer the top salaries, but what we can offer is great benefits. Central Virginia Alliance for Community Living 4

5 The plans in this guide focus on Employer Groups of 1 to 50 total employees. 1 Just 1 Employee The new Self-Employed option for Small Group Plans might be just right. If a self-employed individual doesn t meet the criteria, explore our Individual & Family Plans. (Anyone 65 or more years old is eligible for Medicare Advantage.*) 1-50 Groups of 1-50 Employees Our Small Group Plans are just the right fit. This plan guide provides more details on all of the options and benefits Groups of Employees For groups of that are looking for even more options through level-funded plans, check out the flexibility of our BusinessEDGE plans. Refer to our 2019 Mid-Market and Large Group guide for plans that focus on employer groups of 51 or more employees Groups with 51 or more employees and 150 or less eligible employees Mid-Market BusinessEDGE Groups with 151 or more eligible employees Large Group Optima Health is a comprehensive health plan provider, serving Virginia with a variety of plans for Employer Groups, Sole Proprietors, Individuals and Families, Medicare and Medicaid Recipients. For information on other size groups, or plans for other needs, please contact your Optima Health Representative. *Optima Medicare Advantage HMO is currently offered in Hampton Roads SMALL GROUP GUIDE 5

6 How Can We Help You Today? Outstanding Provider Access Our committed, high-quality networks include the Optima Health statewide networks, PHCS, MDLIVE, EyeMed and American Specialty Health Group (ASH). The percentage of providers with a favorable impression of Optima Health is 93%. 1 Our providers continually rank us high for service, consistently outranking other comparable health plans, 1 and our voluntary turnover rate is less than 1%. 2 The PHCS Network offers participants access in all states regardless of where they live, work, and seek healthcare giving them access to the largest independent primary PPO in the nation. Through our Clinically Integrated Network SQCN select providers have voluntarily joined together to help transform healthcare which ultimately results in lower costs for members through new models of care management. Members benefit from receiving the right care, at the right place, and the right time. 1 Optima Health Customer Service Monthly Report Cards, May Statewide Voluntary Network Turnover Worksheet, July

7 MDLIVE Anytime, anywhere, affordable, quality, virtual healthcare, 24/7/365. MDLIVE offers on-demand access to a network of board-certified physicians to diagnose, recommend treatment, and prescribe medication. Getting employees and their dependents the care they need, when they need it. MDLIVE for non-emergency illness and injury such as: Allergies Earache Asthma Joint Aches and Pain Bronchitis Respiratory Infection Cold and Flu Sinus Problems Members can use this easy-toaccess service to consult with a provider and start any needed treatment fast. It s an option that can reduce absenteeism and time off for appointments. ALWAYS INNOVATING Transparency Tool Provides localized, provider-specific, out-of-pocket cost estimates for over 500 procedures and services based on the member s specific benefit plan and their actual deductible and max out-of-pocket satisfaction to date. Emergency Travel Assistance Program Fully paid, global emergency, medically related assistance services are provided by Assist America and available to all fully insured Optima Health members. With the Emergency Travel Assistance Program, Optima Health members are protected with resources whenever they travel 100 miles or more from home. Employee Assistance Visits A unique, flexible approach in assisting employees with personal and workplace issues. All fully insured plans include the Optima Health Employee Assistance Visits. Through free, face-to-face counseling visits with local mental health professionals, our members can better manage work and life issues so they may stay focused and productive. Alternative Medicine Discount Program Discounts for programs that include acupuncture, chiropractic, and massage therapy services. 24/ SMALL GROUP GUIDE 7

8 Healthy Employees: Healthy for Business Healthy employees are vital to a successful business. As part of an integrated health system, Optima Health truly believes in improving health every day. That s why all of our health plans include MyLife MyPlan a flexible health improvement program that helps members adopt healthy behaviors, reduce health risks, and lower healthcare costs. WebMD Health Services powers this resource with a Personal Health Assessment and a comprehensive online activities tool, the Digital Health Assistant (DHA), to provide a personalized, interactive, and motivational experience to help members take action and sustain healthy behaviors. WORKSITE PROGRAMS Optima Health provides insured groups a variety of educational programs and on-site screenings, with a minimum of 20 enrolled employees, to help employees manage their health. Health Risks Programs educate employees about health risks and how to prevent disease, with topics such as high blood pressure and cholesterol. Physical Activity and Movement Programs focus on the importance of an active lifestyle, and provide guidance on making exercise a lifestyle choice and walking your way to better health. Tobacco Cessation Awareness Program offers tips on how to help someone quit using tobacco products. Participants learn about nicotine addiction and effective ways to control dependency. Nutrition and Healthy Eating Programs teach about reading and understanding food labels, and how to make the best food choices for good health. Go to to find out more. 8

9 SELF-PACED, STAYING HEALTHY PROGRAMS An award-winning collection of nutrition, fitness, tobacco cessation, and healthy programs to help employees improve their health on their own schedule. For immediate access to the programs listed below visit Eating for Life is an award-winning educational program that helps participants develop healthy eating and exercise habits. Get Off Your Butt: Stay Smokeless for Life is an educational program offering support for anyone who wants to quit tobacco use. Guided Meditation is a program that invites listeners to experience a calm, peaceful retreat from everyday stress. Healthy Habits Healthy You is a program that offers helpful ways to prevent type 2 diabetes and heart disease through making healthy food choices, managing body weight, exercising, and finding ways to relax and get more sleep. Gym Network 360 provides access to premier fitness, weight loss, and wellness brands at discounted pricing. MOVEMENT PROGRAMS Tai Chi helps your body to mentally and physically relax. The movements enhance your blood flow, release muscle tension, and improve your balance. WalkAbout with Healthy Edge focuses on increasing regular activity. It includes an activity tracking device and encourages participants to start moving and begin walking toward better health. We choose Optima Health because it truly gives my employees peace of mind. Yoga programs include stretching and strengthening exercises to help improve flexibility, strength, and cardiovascular health. Chair Yoga is also available. Blue Ridge Area Food Bank 2019 SMALL GROUP GUIDE 9

10 It s All About Choice Our new network and plan designs offer lower cost options for your groups and their employees! NAVIGATING THE 2019 PLAN OPTIONS Our Plan Names include a combination of the following components: Product Type + Product Line + Metallic Tier + Individual Deductible/Copayment/Coinsurance + Network + Region For Example: HMO HSA Silver plan with a $2700 Individual Deductible, 10% Coinsurance, and a Tiered network: Optima Vantage Equity Silver 2700/10% Direct PLAN NAMES HMO: Vantage No referrals required Select your PCP Open access PPO: Plus Access to a national provider network at in-network rates In and out-ofnetwork benefits POS: HMO/PPO hybrid No referral required Select your PCP Includes out-ofnetwork option Open access PRODUCT LINES HSA: Equity Employers and employees contribute tax-free income for qualified medical expenses. These accounts are easy to manage, with integrated claims accessed through the Optima Health online portal. There are no account management or HSA administration fees. HRA: Design Employer-funded health benefit plan that reimburses employees for some of their out-of-pocket medical expenses. All unused funds remain with the employer. 10

11 DIRECT & SELECT PLANS Direct Plans Select and Direct Plans Unavailable Direct Direct Network plans offer our full network of physicians and facilities. Members maximize cost savings when using Tier 1 physicians and facilities. Available in Vantage (HMO), Plus (PPO), and POS plans. TIER 1 $ TIER 2 $$ Select Select Network plans include access to local physicians and facilities to provide members high quality and efficient care. Available in Vantage (HMO) plans. Offered only in the Charlottesville MSA. Emergency care received from an out-of-network (OON) physician or facility will be covered at the in-network rate, for both Direct and Select plans SMALL GROUP GUIDE 11

12 2019 Optima Vantage Plans Plan Name Optima Vantage Platinum 10/20 Direct Optima Vantage Platinum 15/35 Direct Optima Vantage Platinum 20/20% Rx Ded Direct Plan Name Charlottesville Optima Vantage Platinum 10/20 Direct CH Optima Vantage Platinum 15/35 Direct CH Optima Vantage Platinum 20/20% Rx Ded Direct CH Plan Name Rockingham Optima Vantage Platinum 10/20 Direct RK Optima Vantage Platinum 15/35 Direct RK Optima Vantage Platinum 20/20% Rx Ded Direct RK Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family N/A N/A N/A Max Out-of-Pocket Individual/Family $4,500/$9,000 $3,000/$6,000 $3,500/$7,000 Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) $10/$20 $15/$30 $20/$40 Virtual Consult $10 $15 $20 Specialist Visit (Tier 1/Tier 2 physicians) $20/$40 $35/$70 $40/$80 Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) $200/$300 $150/$250 20%/40% Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) $20/$40 $35/$70 20%/40% Outpatient Lab Work (Tier 1/Tier 2 facilities) $20/$40 $35/$70 20%/40% Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities and physicians) $150/$300 $150/$300 20%/40% Inpatient Services Inpatient Hospital Services (Tier 1/Tier 2 facilities) $250 copay/day/$1,000 max $500 copay/day/$2,000 max $300 copay/day/$1,200 max $600 copay/day/$2,400 max 20%/40% Emergency & Urgent Care Services Emergency Services (In or Out-of-Network) $250 $250 30% Urgent Care $20 $35 $40 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) $250 copay/day $1,000 max $500 copay/day $2,000 max $300 copay/day/$1,200 max $600 copay/day/$2,400 max 20%/40% Outpatient Office Visits (Tier 1/Tier 2 physicians) $10/$20 $15/$30 $20/$40 Other Outpatient Visits (Tier 1/Tier 2 facilities) $10/$20 $15/$30 20%/40% Employee Assistance Visits Diabetes Treatment Insulin Pumps 0% 0% 0% Pump Infusion Sets & Supplies 0% 20% 20% Testing Supplies Other Covered Services Adult Preventive Vision Exams 1 covered visit every 12 months 1 covered visit every 12 months 1 covered visit every 12 months Chiropractic Care (Spinal Manipulation) $10 20% 20% Maternity Care (Tier 1/Tier 2 physicians) $200/$350 $350/$450 $450/$600 Pharmacy Prescription Drug Coverage $5/$35/20%/20%* ($350) $10/$40/20%/20%* ($350) Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD* ($350) 12

13 AD: After Deductible p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. Optima Vantage Platinum 25/50 Direct Optima Vantage Platinum 25/50 Direct CH Optima Vantage Platinum 25/50 Direct RK Optima Vantage Platinum 25/50 Rx Ded Direct Optima Vantage Platinum 25/50 Rx Ded Direct CH Optima Vantage Platinum 25/50 Rx Ded Direct RK Embedded Embedded Embedded N/A N/A N/A 35/30% Rx Ded Direct 35/30% Rx Ded Direct CH 35/30% Rx Ded Direct RK $2,500/$5,000 $2,500/$5,000 $6,850/$13,700 $25/$50 $25/$50 $35/$70 $25 $25 $35 $50/$100 $50/$100 $70/$140 $300/$600 $300/$600 30%/50% 2019 OPTIMA VANTAGE PLANS $50/$100 $50/$100 30%/50% $50/$100 $50/$100 30%/50% $150/$300 $150/$300 30%/50% $300 copay/day/$1,200 max $600 copay/day/$2,400 max $300 copay/day/$1,200 max $600 copay/day/$2,400 max 30%/50% $250 $250 40% $50 $50 $70 $300 copay/day/$1,200 max $600 copay/day/$2,400 max $300 copay/day/$1,200 max $600 copay/day/$2,400 max 30%/50% $25/$50 $25/$50 $35/$70 $25/$50 $25/$50 30%/50% 0% 0% 0% 20% 20% 30% 1 covered visit every 12 months 1 covered visit every 12 months 1 covered visit every 12 months 20% 20% 30% $500/$650 $500/$650 $500/$650 $10/$40/20%/20%* ($350) Rx p/p Deductible $100 $10/$40 AD/20% AD/20% AD* ($350) Rx p/p Deductible $100 $10/$40 AD/30% AD/30% AD* ($350) 13

14 2019 Optima Vantage Plans (continued) Plan Name 500/25/20% Rx Ded Direct 1000/20/20% Rx Ded Direct 1000/25/30% Rx Ded Direct Plan Name Charlottesville 500/25/20% Rx Ded Direct CH 1000/20/20% Rx Ded Direct CH 1000/25/30% Rx Ded Direct CH Plan Name Rockingham 500/25/20% Rx Ded Direct RK 1000/20/20% Rx Ded Direct RK 1000/25/30% Rx Ded Direct RK Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family $500/$1,000 $1,000/$2,000 $1,000/$2,000 Max Out-of-Pocket Individual/Family $6,000/$12,000 $4,500/$9,000 $4,000/$8,000 Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) $25/$50 $20/$40 $25/$50 Virtual Consult $25 $20 $25 Specialist Visit (Tier 1/Tier 2 physicians) $50/$100 $40 AD/$80 AD $50 AD/$100 AD Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) $50/$100 20% AD/40% AD 30% AD/50% AD Outpatient Lab Work (Tier 1/Tier 2 facilities) $50/$100 20% AD/40% AD 30% AD/50% AD Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities and physicians) 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD Inpatient Services Inpatient Hospital Services (Tier 1/Tier 2 facilities) 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-Network) 30% AD 30% AD 40% AD Urgent Care $50 $40 AD $50 AD Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD Outpatient Office Visits (Tier 1/Tier 2 physicians) $25/$50 $20/$40 $25/$50 Other Outpatient Visits (Tier 1/Tier 2 facilities) 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD Employee Assistance Visits Diabetes Treatment Insulin Pumps 0% 0% 0% Pump Infusion Sets & Supplies 20% AD 20% AD 30% AD Testing Supplies Other Covered Services Adult Preventive Vision Exams 1 covered visit every 12 months 1 covered visit every 12 months 1 covered visit every 12 months Chiropractic Care (Spinal Manipulation) 20% AD 20% AD 30% AD Maternity Care (Tier 1/Tier 2 physicians) $450/$600 $450/$600 $500/$650 Pharmacy 14 Prescription Drug Coverage Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD* ($350) Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD* ($350) Rx p/p Deductible $200 $15/$50 AD/30% AD/30% AD* ($350)

15 AD: After Deductible p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. 1500/30/0% Rx Ded Direct 1500/30/0% Rx Ded Direct CH 1500/30/0% Rx Ded Direct RK 1500/25/20% Rx Ded Direct 1500/25/20% Rx Ded Direct CH 1500/25/20% Rx Ded Direct RK Embedded Embedded Embedded 2000/25/30% Direct 2000/25/30% Direct CH 2000/25/30% Direct RK $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $7,150/$14,300 $4,000/$8,000 $4,000/$8,000 $30/$60 $25/$50 $25/$50 $30 $25 $25 $60/$120 $50/$100 $50/$ OPTIMA VANTAGE PLANS 0% AD/20% AD 20% AD/40% AD 30% AD/50% AD $60/$120 20% AD/40% AD 30% AD/50% AD $30/$60 20% AD/40% AD 30% AD/50% AD $300/$600 20% AD/40% AD 30% AD/50% AD 0% AD/20% AD 20% AD/40% AD 30% AD/50% AD 20% AD 30% AD 40% AD $60 $40 $50 0% AD/20% AD 20% AD/40% AD 30% AD/50% AD $30/$60 $25/$50 $25/$50 0% AD/20% AD 20% AD/40% AD 30% AD/50% AD 0% 0% 0% 0% AD 20% AD 30% AD 1 covered visit every 12 months 1 covered visit every 12 months 1 covered visit every 12 months 0% AD 20% AD 30% AD 0% AD/20% AD $450/$600 $500/$650 Rx p/p Deductible $200 $25/$50 AD/25% AD/25% AD* ($350) Rx p/p Deductible $200 $15/$50 AD/20% AD/20% AD* ($350) $15/$50/30%/30%* ($350) 15

16 2019 Optima Vantage Plans (continued) Plan Name 2000/25/30% Rx Ded Direct 2500/35/0% Rx Ded Direct Optima Vantage Silver 3000/35/25% Direct Plan Name Charlottesville 2000/25/30% Rx Ded Direct CH 2500/35/0% Rx Ded Direct CH Optima Vantage Silver 3000/35/25% Direct CH Plan Name Rockingham 2000/25/30% Rx Ded Direct RK 2500/35/0% Rx Ded Direct RK Optima Vantage Silver 3000/35/25% Direct RK Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family $2,000/$4,000 $2,500/$5,000 $3,000/$6,000 Max Out-of-Pocket Individual/Family $4,000/$8,000 $7,150/$14,300 $7,350/$14,700 Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) $25/$50 $35/$70 $35/$70 Virtual Consult $25 $35 $35 Specialist Visit (Tier 1/Tier 2 physicians) $50/$100 $65/$130 $70/$140 Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD Outpatient Lab Work (Tier 1/Tier 2 facilities) 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities and physicians) 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD Inpatient Services Inpatient Hospital Services (Tier 1/Tier 2 facilities) 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-Network) 40% AD 20% AD 35% AD Urgent Care $50 0% AD $70 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD Outpatient Office Visits (Tier 1/Tier 2 physicians) $25/$50 $35/$70 $35/$70 Other Outpatient Visits (Tier 1/Tier 2 facilities) 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD Employee Assistance Visits Diabetes Treatment no copay required no copay required Insulin Pumps 0% 0% 0% Pump Infusion Sets & Supplies 30% AD 0% AD 25% AD Testing Supplies Other Covered Services Adult Preventive Vision Exams 1 covered visit every 12 months 1 covered visit every 12 months 1 covered visit every 12 months Chiropractic Care (Spinal Manipulation) 30% AD 0% AD 25% AD Maternity Care (Tier 1/Tier 2 physicians) $500/$650 $500/$650 25% AD/45% AD Pharmacy Prescription Drug Coverage Rx p/p Deductible $100 $15/$50 AD/30% AD/30% AD* ($350) Rx p/p Deductible $200 $15 AD/$50 AD/25% AD/ 25% AD* ($350) $15 AD/$50 AD/25% AD/ 25% AD* ($350) 16

17 AD: After Deductible p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. Optima Vantage Silver 3700/40/20% Rx Ded Direct Optima Vantage Silver 5000/40/20% Direct Optima Vantage Bronze 6600/30% Direct Optima Vantage Silver 3700/40/20% Rx Ded Direct CH Optima Vantage Silver 5000/40/20% Direct CH Optima Vantage Bronze 6600/30% Direct CH Optima Vantage Silver 3700/40/20% Rx Ded Direct RK Optima Vantage Silver 5000/40/20% Direct RK Optima Vantage Bronze 6600/30% Direct RK Embedded Embedded Embedded $3,700/$7,400 $5,000/$10,000 $6,600/$13,200 $7,500/$15,000 $7,350/$14,700 $7,800/$15,600 $40/$80 $40/$80 $45/first 3 visits; then 30% AD $90/first 3 visits; then 30% AD $40 $40 $45 for first 3 visits; then 30% AD $80/$160 $80/$160 30% AD/50% AD 2019 OPTIMA VANTAGE PLANS 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD 30% AD 30% AD 40% AD $80 $80 30% AD 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD $40/$80 $40/$80 10%/30% 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD 0% 0% 0% 20% AD 20% AD 30% AD 1 covered visit every 12 months 1 covered visit every 12 months 1 covered visit every 12 months 20% AD 20% AD 30% AD 20% AD/40% AD 20% AD/40% AD 30% AD/50% AD Rx p/p Deductible $150 $15 AD/$50 AD/20% AD/20% AD* ($350) $10/$40/20%/20%* ($350) 30% AD/30%AD/30%AD/30%AD* ($350) 17

18 2019 Optima Vantage Equity Plans Plan Name Optima Vantage Equity Silver 2700/10% Direct Optima Vantage Equity Silver 3000/20% Direct Plan Name Charlottesville Optima Vantage Equity Silver 2700/10% Direct CH Optima Vantage Equity Silver 3000/20% Direct CH Plan Name Rockingham Optima Vantage Equity Silver 2700/10% Direct RK Optima Vantage Equity Silver 3000/20% Direct RK Embedded/Non-Embedded Embedded Embedded Deductible Individual/Family (No 4th Quarter Deductible Carryover on Equity Plans) $2,700/$5,400 $3,000/$6,000 Max Out-of-Pocket Individual/Family $6,000/$12,000 $6,000/$12,000 Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) 10% AD/30% AD 20% AD/40% AD Virtual Consult 10% AD 20% AD Specialist Office Visit (Tier 1/Tier 2 physicians) 10% AD/30% AD 20% AD/40% AD Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) 10% AD/30% AD 20% AD/40% AD Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) 10% AD/30% AD 20% AD/40% AD Outpatient Lab Work (Tier 1/Tier 2 facilities) 10% AD/30% AD 20% AD/40% AD Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities & physicians) Inpatient Services 10% AD/30% AD 20% AD/40% AD Inpatient Hospital Services (Tier 1/Tier 2 facilities) 10% AD/30% AD 20% AD/40% AD Emergency & Urgent Care Service Emergency Services (In or Out-of-Network) 20% AD 30% AD Urgent Care 10% AD 20% AD Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) 10% AD/30% AD 20% AD/40% AD Outpatient Office Visits (Tier 1/Tier 2 physicians) 10% AD/30% AD 20% AD/40% AD Other Outpatient Visits (Tier 1/Tier 2 facilities) 10% AD/30% AD 20% AD/40% AD Employee Assistance Visits Diabetes Treatment for each individual covered; for each individual covered; Insulin Pumps 10% AD 20% AD Pump Infusion Sets and Supplies 10% AD 20% AD Testing Supplies 10% AD 20% AD Other Covered Services Adult Preventive Vision Exams 0% for 1 visit every 12 months 0% for 1 visit every 12 months Chiropractic Care (Spinal Manipulation) 10% AD 20% AD Maternity Care (Tier 1/Tier 2 physicians) 10% AD/30% AD 20% AD/40% AD Pharmacy Prescription Drug Coverage $15 AD/$50 AD/10% AD/10% AD* ($350) $15 AD/$50 AD/20% AD/20% AD* ($350) 18

19 AD: After Deductible p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. Optima Vantage Equity Silver 4000/0% Direct Optima Vantage Equity Bronze 5400/40% Direct Optima Vantage Equity Bronze 6500/0% Direct Optima Vantage Equity Silver 4000/0% Direct CH Optima Vantage Equity Bronze 5400/40% Direct CH Optima Vantage Equity Bronze 6500/0% Direct CH Optima Vantage Equity Silver 4000/0% Direct RK Optima Vantage Equity Bronze 5400/40% Direct RK Optima Vantage Equity Bronze 6500/0% Direct RK Embedded Embedded Embedded $4,000/$8,000 $5,400/$10,800 $6,500/$13,000 $6,650/$13,300 $6,650/$13,300 $6,650/$13,300 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD 40% AD 0% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 2019 OPTIMA VANTAGE EQUITY PLANS 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 20% AD 50% AD 20% AD 0% AD 40% AD 0% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD 40% AD 0% AD 0% AD 40% AD 0% AD 0% AD 40% AD 0% AD 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% AD 40% AD 0% AD 0% AD/20% AD 40% AD/60% AD 0% AD/20% AD 0% AD/0% AD/0% AD/0% AD $15 AD/$50 AD/40% AD/40% AD* ($350) 0% AD/0% AD/0% AD/0% AD 19

20 2019 Optima POS Plans Plan Name Plan Name Charlottesville Plan Name Rockingham Optima POS Platinum 10/20 Direct Optima POS Platinum 10/20 Direct CH Optima POS Platinum 10/20 Direct RK Optima POS Platinum 15/35 Direct Optima POS Platinum 15/35 Direct CH Optima POS Platinum 15/35 Direct RK Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family (In Network) None None $500/$1,000 Optima POS Gold 500/25/20% Rx Ded Direct Deductible Individual/Family (Out-of-network) $2,000/$4,000 $2,000/$4,000 $1,000/$2,000 Optima POS Gold 500/25/20% Rx Ded Direct CH Optima POS Gold 500/25/20% Rx Ded Direct RK Max Out-of-Pocket Individual/Family (In Network) $4,500/$9,000 $3,000/$6,000 $6,000/$12,000 Max Out-of-Pocket Individual/Family (Out-of-network) $9,000/$18,000 $6,000/$12,000 $12,000/$24,000 Out-of-Network Coinsurance 30% AD/AC 40% AD/AC 40% AD/AC Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) $10/$20 $15/$30 $25/$50 Virtual Consult (No Out-of-Network Coverage) $10 $15 $25 Specialist Office Visit (Tier 1/Tier 2 physicians) $20/$40 $35/$70 $50/$100 Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) $200/$300 $150/$250 20% AD/40% AD Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) $20/$40 $35/$70 $50/$100 Outpatient Lab Work (Tier 1/Tier 2 facilities) $20/$40 $35/$70 $50/$100 Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities & physicians) Inpatient Services Inpatient Hospital Services (Tier 1/Tier 2 facilities) Emergency & Urgent Care Services $150/$300 $150/$300 20% AD/40% AD $250 copay/day/$1,000 max $500 copay/day/$2,000 max $300 copay/day/$1,200 max $600 copay/day/$2,400 max Emergency Services (In or Out-of-Network) $250 $250 30% AD Urgent Care $20 $35 $50 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) $250 copay/day/$1,000 max $500 copay/day/$2,000 max $300 copay/day/$1,200 max $600 copay/day/$2,400 max Outpatient Office Visits (Tier 1/Tier 2 physicians) $10/$20 $15/$30 $25/$50 20% AD/40% AD 20% AD/40% AD Other Outpatient Visits (Tier 1/Tier 2 facilities) $10/$20 $15/$30 20% AD/40% AD Employee Assistance Visits Diabetes Treatment no copay required no copay required Insulin Pumps 0% 0% 0% Pump Infusion Sets and Supplies 0% 20% 20% AD Testing Supplies Other Covered Services Adult Preventive Vision Exams 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months Chiropractic Care (Spinal Manipulation) $10 20% 20% AD Maternity Care (Tier 1/Tier 2 physicians) $200/ $350 $350/$450 $450/$ Pharmacy Prescription Drug Coverage $5/$35/20%/20%* ($350) $10/$40/20%/20%* ($350) Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD* ($350)

21 AD: After Deductible AC: Allowable Charge p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Out-of-network (OON) amounts may vary. Please see planspecific summary for more information. Care coinsurance amounts represent the percentage the member pays. Optima POS Gold 1000/25/30% Direct Optima POS Gold 1000/25/30% Direct CH Optima POS Gold 1000/25/30% Direct RK Optima POS Gold 1500/30/0% Rx Ded Direct Optima POS Gold 1500/30/0% Rx Ded Direct CH Optima POS Gold 1500/30/0% Rx Ded Direct RK Optima POS Gold 2000/25/30% Direct Optima POS Gold 2000/25/30% Direct CH Optima POS Gold 2000/25/30% Direct RK Optima POS Gold 2500/35/0% Rx Ded Direct Optima POS Gold 2500/35/0% Rx Ded Direct CH Optima POS Gold 2500/35/0% Rx Ded Direct RK Optima POS Silver 3000/35/25% Direct Optima POS Silver 3000/35/25% Direct CH Optima POS Silver 3000/35/25% Direct RK Optima POS Silver 3500/20% Direct Optima POS Silver 3500/20% Direct CH Optima POS Silver 3500/20% Direct RK Embedded Embedded Embedded Embedded Embedded Embedded $1,000/$2,000 $1,500/$3,000 $2,000/$4,000 $2,500/$5,000 $3,000/$6,000 $3,500/$7,000 $2,000/$4,000 $5,000/$10,000 $4,000/$8,000 $5,000/$10,000 $6,000/$12,000 $7,000/$14,000 $4,000/$8,000 $7,150/$14,300 $4,000/$8,000 $7,150/$14,300 $7,350/$14,700 $6,000/$12,000 $8,000/$16,000 $10,000/$20,000 $8,000/$16,000 $14,300/$28,600 $14,700/$29,400 $12,000/$24,000 50% AD/AC 30% AD/AC 50% AD/AC 30% AD/AC 45% AD/AC 40% AD/AC 2019 OPTIMA POS PLANS $25/$50 $30/$60 $25/$50 $35/$70 $35/$70 $35/$70 $25 $30 $25 $35 $35 $35 $50 AD/$100 AD $60/$120 $50/$100 $65/$130 $70/$140 $70/$140 30% AD/50% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 30% AD/50% AD $60/$120 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 30% AD/50% AD $30/$60 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 30% AD/50% AD $300/$600 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 30% AD/50% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 40% AD 20% AD 40% AD 20% AD 35% AD 30% AD $50 AD $60 $50 0% AD $70 $70 30% AD/50% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD $25/$50 $30/$60 $25/$50 $35/$70 $35/$70 $35/$70 30% AD/50% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 3 sessions per presenting issue for each individual covered; no copay required 3 sessions per presenting issue for each individual covered; no copay required 3 sessions per presenting issue for each individual covered; 3 sessions per presenting issue for each individual covered; 0% 0% 0% 0% 0% 0% 30% AD 0% AD 30% AD 0% AD 25% AD 20%AD 0% under the Plan s Prescription 0% under the Plan s Prescription 0% under the Plan s Prescription 0% under the Plan s Prescription 0% under the Plan s Prescription. 0% under the Plan s Prescription 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 30% AD 0% AD 30% AD 0% AD 25% AD 20% AD 0% for 1 visit every 12 months $500/$650 0% AD/20% AD $500/$650 $500/$650 25% AD/45% AD 20% AD/40% AD $15/$50/30%/30%* ($350) Rx p/p Deductible $200 $25/$50 AD/25% AD/ 25% AD* ($350) $15/$50/30%/30%* ($350) Rx p/p Deductible $200 $15 AD/$50 AD/25% AD/ 25% AD* ($350) $15 AD/$50 AD/25% AD/ 25% AD* ($350) $15 AD/$50 AD/ 20% AD/20% AD* ($350) 21

22 2019 Optima POS Equity Plans and POS Design Plans Plan Name Plan Name Charlottesville Plan Name Rockingham Optima POS Equity Silver 3000/20% Direct Optima POS Equity Silver 3000/20% Direct CH Optima POS Equity Silver 3000/20% Direct RK Optima POS Equity Silver 4000/0% Direct Optima POS Equity Silver 4000/0% Direct CH Optima POS Equity Silver 4000/0% Direct RK Optima POS Equity Bronze 5500/40/30% Direct Optima POS Equity Bronze 5500/40/30% Direct CH Optima POS Equity Bronze 5500/40/30% Direct RK Embedded/Non-Embedded Embedded Embedded Embedded Embedded Deductible Individual/Family (In Network; No 4th Quarter Deductible Carryover on Equity Plans) Deductible Individual/Family (Out-of-network; No 4th Quarter Deductible Carryover on Equity Plans) Optima POS Equity Bronze 6500/0% Direct Optima POS Equity Bronze 6500/0% Direct CH Optima POS Equity Bronze 6500/0% Direct RK $3,000/$6,000 $4,000/$8,000 $5,500/$11,000 $6,500/$13,000 $6,000/$12,000 $8,000/$16,000 $11,000/$22,000 $13,000/$26,000 Max Out-of-Pocket Individual/Family (In Network) $6,000/$12,000 $6,650/$13,300 $6,650/$13,300 $6,650/$13,300 Max Out-of-Pocket Individual/Family (Out-of-network) $12,000/$24,000 $13,300/$26,600 $13,300/$26,600 $15,000/$30,000 Out-of-Network Coinsurance 40% AD/AC 30% AD/AC 50% AD/AC 30% AD/AC Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) 20% AD/40% AD 0% AD/20% AD $40 AD/$80 AD 0% AD/20% AD Virtual Consult (No Out-of-Network Coverage) 20% AD 0% AD $40 AD 0% AD Specialist Visit (Tier 1/Tier 2 physicians) 20% AD/40% AD 0% AD/20% AD $80 AD/$160 AD 0% AD/20% AD Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) 20% AD/40% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) 20% AD/40% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD Outpatient Lab Work (Tier 1/Tier 2 facilities) 20% AD/40% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities and physicians) Inpatient Services 20% AD/40% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD Inpatient Hospital Services (Tier 1/Tier 2 facilities) 20% AD/40% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-Network) 30% AD 20% AD 40% AD 20% AD Urgent Care 20% AD 0% AD 30% AD 0% AD Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) 20% AD/40% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD Outpatient Office Visits (Tier 1/Tier 2 physicians) 20% AD/40% AD 0% AD/20% AD $40 AD/$80 AD 0% AD/20% AD Other Outpatient Visits (Tier 1/Tier 2 facilities) 20% AD/40% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD Employee Assistance Visits Diabetes Treatment Insulin Pumps 20% AD 0% AD 30% AD 0% AD Pump Infusion Sets and Supplies 20% AD 0% AD 30% AD 0% AD Testing Supplies 20% AD 0% AD 30% AD 0% AD Other Covered Services Adult Preventive Vision Exams Chiropractic Care (Spinal Manipulation) 20% AD 0% AD 30% AD 0% AD Maternity Care (Tier 1/Tier 2 physicians) 20% AD/40% AD 0% AD/20% AD 30% AD/50% AD 0% AD/20% AD Pharmacy [ ] [ % for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only ] 22 Prescription Drug Coverage Tier 1/Tier 2/Tier 3/Tier 4 (*max out-of-pocket, per prescription) $15 AD/$50 AD/20% AD/20% AD* ($350) 0% AD/0% AD/0% AD/ 0% AD 30% AD/30% AD/ 30% AD/30% AD* ($350) 0% AD/0% AD/0% AD/ 0% AD

23 AD: After Deductible AC: Allowable Charge p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Out-of-network (OON) amounts may vary. Please see plan-specific summary for more information. Coinsurance amounts represent the percentage the member pays. Plan Name Plan Name Charlottesville Plan Name Rockingham Optima POS Design Silver 2000/30% Rx Ded Direct Optima POS Design Silver 2000/30% Rx Ded Direct CH Optima POS Design Silver 2000/30% Rx Ded Direct RK Optima POS Design Silver 3000/20% Rx Ded Direct Optima POS Design Silver 3000/20% Rx Ded Direct CH Optima POS Design Silver 3000/20% Rx Ded Direct RK Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family (In Network; No 4th Quarter Deductible Carryover on Design Plans) Deductible Individual/Family (Out-of-network; No 4th Quarter Deductible Carryover on Design Plans) Optima POS Design Silver 4000/0% Rx Ded Direct Optima POS Design Silver 4000/0% Rx Ded Direct CH Optima POS Design Silver 4000/0% Rx Ded Direct RK $2,000/$4,000 $3,000/$6,000 $4,000/$8,000 $4,000/$8,000 $6,000/$12,000 $8,000/$16,000 Max Out-of-Pocket Individual/Family (In Network) $7,150/$14,300 $5,700/$11,400 $7,500/$15,000 Max Out-of-Pocket Individual/Family (Out-of-network) $14,300/$28,600 $11,400/$22,800 $15,000/$30,000 Out-of-Network Coinsurance 50% AD/AC 40% AD/AC 30% AD/AC Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Virtual Consult (No Out-of-Network Coverage) 30% AD 20% AD 0% AD Specialist Visit (Tier 1/Tier 2 physicians) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Outpatient Lab Work (Tier 1/Tier 2 facilities) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities & physicians) Inpatient Services 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Inpatient Hospital Services (Tier 1/Tier 2 facilities) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-Network) 40% AD 30% AD 20% AD Urgent Care 30% AD 20% AD 0% AD Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Outpatient Office Visits (Tier 1/Tier 2 physicians) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Other Outpatient Visits (Tier 1/Tier 2 facilities) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Employee Assistance Visits Diabetes Treatment no copay required no copay required Insulin Pumps 0% 0% 0% Pump Infusion Sets and Supplies 30% AD 20% AD 0% AD Testing Supplies Other Covered Services Adult Preventive Vision Exams 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only Chiropractic Care (Spinal Manipulation) 30% AD 20% AD 0% AD no copay required 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only Maternity Care (Tier 1/Tier 2 physicians) 30% AD/50% AD 20% AD/40% AD 0% AD/20% AD Pharmacy Prescription Drug Coverage Rx p/p Deductible $150 $10/$40 AD/30% AD/30% AD* ($350) Rx p/p Deductible $150 $15 AD/$50 AD/20% AD/ 20% AD* ($350) Rx p/p Deductible $250 $25 AD/$75 AD/20% AD/ 20% AD* ($350) 2019 OPTIMA POS EQUITY PLANS AND POS DESIGN PLANS 23

24 2019 Optima Plus Plans Plan Name Plan Name Charlottesville Plan Name Rockingham Optima Plus Platinum 10/20 Direct Optima Plus Platinum 10/20 Direct CH Optima Plus Platinum 10/20 Direct RK Embedded/Non-Embedded Embedded Embedded Deductible Individual/Family (In Network) None None Optima Plus Platinum 15/35 Direct Optima Plus Platinum 15/35 Direct CH Optima Plus Platinum 15/35 Direct RK Deductible Individual/Family (Out-of-network) $2,000/$4,000 $2,000/$4,000 Max Out-of-Pocket Individual/Family (In Network) $4,500/$9,000 $3,000/$6,000 Max Out-of-Pocket Individual/Family (Out-of-network) $9,000/$18,000 $6,000/$12,000 Out-of-Network Coinsurance 30% AD/AC 40% AD/AC Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) $10/$20 $15/$30 Virtual Consult (No Out-of-Network Coverage) $10 $15 Specialist Visit (Tier 1/Tier 2 physicians) $20/$40 $35/$70 Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) $200/$300 $150/$250 Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) $20/$40 $35/$70 Outpatient Lab Work (Tier 1/Tier 2 facilities) $20/$40 $35/$70 Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities & physicians) Inpatient Services Inpatient Hospital Services (Tier 1/Tier 2 facilities) Emergency & Urgent Care Services $150/$300 $150/$300 $250 copay/day/$1,000 max $500 copay/day/$2,000 max Emergency Services (In or Out-of-Network) $250 $250 Urgent Care $20 $35 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) $250 copay/day/$1,000 max $500 copay/day/$2,000 max Outpatient Office Visits (Tier 1/Tier 2 physicians) $10/$20 $15/$30 Other Outpatient Visits (Tier 1/Tier 2 facilities) $10/$20 $15/$30 Employee Assistance Visits Diabetes Treatment for each individual covered; Insulin Pumps 0% 0% Pump Infusion Sets and Supplies 0% 20% $300 copay/day/$1,200 max $600 copay/day/$2,400 max $300 copay/day/$1,200 max $600 copay/day/$2,400 max for each individual covered; Testing Supplies Other Covered Services Adult Preventive Vision Exams 0% for 1 visit every 12 months In Network. Max reimbursement of $30 Out-of-Network for eye exam only 0% for 1 visit every 12 months In Network. Max reimbursement of $30 Out-of-Network for eye exam only Chiropractic Care (Spinal Manipulation) $10 20% Maternity Care (Tier 1/Tier 2 physicians) $200/ $350 $350/$450 Pharmacy Prescription Drug Coverage $5/$35/20%/20%* ($350) $10/$40/20%/20%* ($350) 24

25 AD: After Deductible AC: Allowable Charge p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Out-of-network (OON) amounts may vary. Please see plan-specific summary for more information. Coinsurance amounts represent the percentage the member pays. Optima Plus Gold 500/25/20% Rx Ded Direct Optima Plus Gold 500/25/20% Rx Ded Direct CH Optima Plus Gold 500/25/20% Rx Ded Direct RK Optima Plus Gold 1000/20/20% Rx Ded Direct Optima Plus Gold 1000/20/20% Rx Ded Direct CH Optima Plus Gold 1000/20/20% Rx Ded Direct RK Embedded Embedded Embedded Optima Plus Gold 1500/30/0% Rx Ded Direct $500/$1,000 $1,000/$2,000 $1,500/$3,000 Optima Plus Gold 1500/30/0% Rx Ded Direct CH Optima Plus Gold 1500/30/0% Rx Ded Direct RK $1,000/$2,000 $2,000/$4,000 $5,000/$10,000 $6,000/$12,000 $4,500/$9,000 $7,150/$14,300 $12,000/$24,000 $9,000/$18,000 $10,000/$20,000 40% AD/AC 40% AD/AC 30% AD/AC 2019 OPTIMA PLUS PLANS $25/$50 $20/$40 $30/$60 $25 $20 $30 $50/$100 $40 AD/$80 AD $60/$120 20% AD/40% AD 20% AD/40% AD 0% AD/20% AD $50/$100 20% AD/40% AD $60/$120 $50/$100 20% AD/40% AD $30/$60 20% AD/40% AD 20% AD/40% AD $300/$600 20% AD/40% AD 20% AD/40% AD 0% AD/20% AD 30% AD 30% AD 20% AD $50 $40 AD $60 20% AD/40% AD 20% AD/40% AD 0% AD/20% AD $25/$50 $20/$40 $30/$60 20% AD/40% AD 20% AD/40% AD 0% AD/20% AD 0% 0% 0% 20% AD 20% AD 0% AD 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only 0% for 1 visit every 12 months In Network. Max reimbursement of $30 Out-of-Network for eye exam only 20% AD 20% AD 0% AD $450/$600 $450/$600 0% AD/20% AD 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD* ($350) Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD* ($350) Rx p/p Deductible $200 $25/$50 AD/25% AD/25% AD* ($350) 25

26 2019 Optima Plus Plans (continued) Plan Name Plan Name Charlottesville Plan Name Rockingham Optima Plus Gold 1500/25/20% Rx Ded Direct Optima Plus Gold 1500/25/20% Rx Ded Direct CH Optima Plus Gold 1500/25/20% Rx Ded Direct RK Embedded/Non-Embedded Embedded Embedded Optima Plus Gold 2000/25/30% Rx Ded Direct Deductible Individual/Family $1,500/$3,000 $2,000/$4,000 Deductible Individual/Family $3,250/$6,500 $4,000/$8,000 Max Out-of-Pocket Individual/Family (In Network) $4,000/$8,000 $4,000/$8,000 Max Out-of-Pocket Individual/Family (Out-of-network) $8,000/$16,000 $8,000/$16,000 Out-of-Network Benefits Coinsurance 40% AD/AC 50% AD/AC Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) $25/$50 $25/$50 Virtual Consult (No Out-of-Network Coverage) $25 $25 Specialist Visit (Tier 1/Tier 2 physicians) $50/$100 $50/$100 Outpatient Surgery Optima Plus Gold 2000/25/30% Rx Ded Direct CH Optima Plus Gold 2000/25/30% Rx Ded Direct RK Outpatient Surgery (Tier 1/Tier 2 facilities) 20% AD/40% AD 30% AD/50% AD Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) 20% AD/40% AD 30% AD/50% AD Outpatient Lab Work (Tier 1/Tier 2 facilities) 20% AD/40% AD 30% AD/50% AD Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities & physicians) Inpatient Services 20% AD/40% AD 30% AD/50% AD Inpatient Hospital Services (Tier 1/Tier 2 facilities) 20% AD/40% AD 30% AD/50% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-Network) 30% AD 40% AD Urgent Care $40 $50 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services (Tier 1/Tier 2 facilities) 20% AD/40% AD 30% AD/50% AD Outpatient Office Visits (Tier 1/Tier 2 physicians) $25/$50 $25/$50 Other Outpatient Visits (Tier 1/Tier 2 facilities) 20% AD/40% AD 30% AD/50% AD Employee Assistance Visits Diabetes Treatment for each individual covered; Insulin Pumps 0% 0% Pump Infusion Sets and Supplies 20% AD 30% AD for each individual covered; Testing Supplies Other Covered Services Adult Preventive Vision Exams 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only Chiropractic Care (Spinal Manipulation) 20% AD 30% AD Maternity Care (Tier 1/Tier 2 physicians) $450/$600 $500/$650 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only Pharmacy Prescription Drug Coverage Rx p/p Deductible $200 $15/$50 AD/20% AD/20% AD* ($350) Rx p/p Deductible $100 $15/$50 AD/30% AD/30% AD* ($350) 26

27 AD: After Deductible AC: Allowable Charge p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Out-of-network (OON) amounts may vary. Please see plan-specific summary for more information. Coinsurance amounts represent the percentage the member pays. Optima Plus Gold 2500/35/0% Rx Ded Direct Optima Plus Gold 2500/35/0% Rx Ded Direct CH Optima Plus Gold 2500/35/0% Rx Ded Direct RK Optima Plus Silver 3000/35/25% Direct Optima Plus Silver 3000/35/25% Direct CH Optima Plus Silver 3000/35/25% Direct RK Optima Plus Silver 5000/40/20% Direct Optima Plus Silver 5000/40/20% Direct CH Optima Plus Silver 5000/40/20% Direct RK Optima Plus Bronze 5000/20% Direct Optima Plus Bronze 5000/20% Direct CH Optima Plus Bronze 5000/20% Direct RK Embedded Embedded Embedded Embedded $2,500/$5,000 $3,000/$6,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $6,000/$12,000 $10,000/$20,000 $10,000/$20,000 $7,150/$14,300 $7,350/$14,700 $7,350/$14,700 $7,350/$14,700 $14,300/$28,600 $14,700/$29,400 $14,700/$29,400 $14,700/$29,400 30% AD/AC 45% AD/AC 40% AD/AC 40% AD/AC 2019 OPTIMA PLUS PLANS $35/$70 $35/$70 $40/$80 $40 AD/ $80 AD $35 $35 $40 $40 AD $65/$130 $70/$140 $80/$160 $80 AD/$160 AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 20% AD/40% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 20% AD/40% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 20% AD/40% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 20% AD/40% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 20% AD/40% AD 20% AD 35% AD 30% AD 30% AD 0% AD $70 $80 20% AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 20% AD/40% AD $35/$70 $35/$70 $40/$80 $40 AD/$80 AD 0% AD/20% AD 25% AD/45% AD 20% AD/40% AD 20% AD/40% AD for each individual covered; for each individual covered; for each individual covered; for each individual covered; 0% 0% 0% 0% 0% AD 25% AD 20% AD 20%AD Drug Benefit Drug Benefit Drug Benefit Drug Benefit 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only 0% AD 25% AD 20% AD 20% AD $500/$650 25% AD/45% AD 20% AD/40% AD 20% AD/40% AD 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only Rx p/p Deductible $200 $15 AD/$50 AD/25% AD/25% AD* ($350) $15 AD*/$50 AD*/25% AD*/25% AD* ($350) $10/$40/20%/20%* ($350) $15 AD/$50 AD/20% AD/20% AD* ($350) 27

28 2019 Optima Plus Equity Plans Plan Name Optima Plus Equity Silver 2700/10% Direct Plan Name Charlottesville Optima Plus Equity Silver 2700/10% Direct CH Plan Name Rockingham Optima Plus Equity Silver 2700/10% Direct RK Embedded/Non-Embedded Deductible Individual/Family (In Network; No 4th Quarter Deductible Carryover on Equity Plans) Deductible Individual/Family (In Network; No 4th Quarter Deductible Carryover on Equity Plans) Embedded $2,700/$5,400 $5,400/$10,800 Max Out-of-Pocket Individual/Family (In Network) $6,000/$12,000 Max Out-of-Pocket Individual/Family (Out-of-network) $12,000/$24,000 Out-of-Network Coinsurance Physician Services PCP Office Visit (Tier 1/Tier 2 physicians) Virtual Consult (No Out-of-Network Coverage) Specialist Visit (Tier 1/Tier 2 physicians) Outpatient Surgery Outpatient Surgery (Tier 1/Tier 2 facilities) Outpatient Services Outpatient Diagnostic Procedures & Tests (Tier 1/Tier 2 facilities) 30% AD/AC 10% AD/30% AD 10% AD 10% AD/30% AD 10% AD/30% AD 10% AD/30% AD Outpatient Lab Work (Tier 1/Tier 2 facilities) Advanced Imaging & Testing Procedures (Tier 1/Tier 2 facilities and physicians) 10% AD/30% AD 10% AD/30% AD Inpatient Services Inpatient Hospital Services (Tier 1/Tier 2 facilities) Emergency & Urgent Care Services Emergency Services (In or Out-of-Network) Urgent Care Mental/Behavioral Health & Substance Use Disorder Services 10% AD/30% AD 20% AD 10% AD Inpatient Services (Tier 1/Tier 2 facilities) Outpatient Office Visits (Tier 1/Tier 2 physicians) Other Outpatient Visits (Tier 1/Tier 2 facilities) Employee Assistance Visits 10% AD/30% AD 10% AD/30% AD 10% AD/30% AD Diabetes Treatment Insulin Pumps Pump Infusion Sets and Supplies Testing Supplies 10% AD 10% AD 10% AD Other Covered Services Adult Preventive Vision Exams Chiropractic Care (Spinal Manipulation) Maternity Care (Tier 1/Tier 2 physicians) 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only 10% AD 10% AD/30% AD 28 Pharmacy Prescription Drug Coverage $15 AD/$50 AD/10% AD/10% AD* ($350)

29 AD: After Deductible AC: Allowable Charge p/p: Per Person Tier 1: All Optima Health participating providers except those listed as Tier 2 Tier 2: Refer to OptimaHealth.com This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Out-of-network (OON) amounts may vary. Please see plan specific summary for more information. Coinsurance amounts represent the percentage the member pays. Optima Plus Equity Silver 3000/20% Direct Optima Plus Equity Silver 4000/0% Direct Optima Plus Equity Bronze 6500/0% Direct Optima Plus Equity Silver 3000/20% Direct CH Optima Plus Equity Silver 4000/0% Direct CH Optima Plus Equity Bronze 6500/0% Direct CH Optima Plus Equity Silver 3000/20% Direct RK Optima Plus Equity Silver 4000/0% Direct RK Optima Plus Equity Bronze 6500/0% Direct RK Embedded Embedded Embedded $3,000/$6,000 $4,000/$8,000 $6,500/$13,000 $6,000/$12,000 $8,000/$16,000 $13,000/$26,000 $6,000/$12,000 $6,650/$13,300 $6,650/$13,300 $12,000/$24,000 $13,300/$26,600 $15,000/$30,000 40% AD/AC 30% AD/AC 30% AD/AC 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 20% AD 0% AD 0% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 2019 OPTIMA PLUS EQUITY PLANS 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 30% AD 20% AD 20% AD 20% AD 0% AD 0% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 20% AD 0% AD 0% AD 20% AD 0% AD 0% AD 20% AD 0% AD 0% AD 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only 20% AD 0% AD 0% AD 20% AD/40% AD 0% AD/20% AD 0% AD/20% AD 0% for 1 visit every 12 months In Network; Max reimbursement of $30 Out-of-Network for eye exam only $15 AD/$50 AD/20% AD/20% AD* ($350) 0% AD/0% AD/0% AD/0% AD 0% AD/0% AD/0% AD/0% AD 29

30 2019 Optima Vantage Select Plans Plan Name Optima Vantage Platinum 10/20 Select CH Optima Vantage Platinum 15/35 Select CH Optima Vantage Platinum 20/20% Rx Ded Select CH Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family None None None Max Out-of-Pocket Individual/Family $4,500/$9,000 $3,000/$6,000 $3,500/$7,000 Physician Services PCP Office Visit $10 $15 $20 Virtual Consult $10 $15 $20 Specialist Visit $20 $35 $40 Outpatient Surgery Outpatient Surgery $200 $150 20% Outpatient Services Outpatient Diagnostic Procedures & Tests $20 $35 20% Outpatient Lab Work $20 $35 20% Advanced Imaging & Testing Procedures $150 $150 20% Inpatient Services Inpatient Hospital Services $250 copay/day/$1,000 max $300 copay/day/$1,200 max 20% Emergency & Urgent Care Services Emergency Services (In or Out-of-network) $250 $250 30% Urgent Care $20 $35 $40 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services $250 copay/day/$1,000 max $300 copay/day/$1,000 max 20% Outpatient Office Visits $10 $15 $20 Other Outpatient Visits $10 $15 20% Employee Assistance Visits Diabetes Treatment no copay required no copay required Insulin Pumps 0% 0% 0% Pump Infusion Sets & Supplies 0% 20% 20% no copay required Testing Supplies Other Covered Services Adult Preventive Vision Exams 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months Chiropractic Care (Spinal Manipulation) $10 20% 20% Maternity Care $200 $350 $450 Pharmacy Prescription Drug Coverage $5/$35/20%/20%* ($350) $10/$40/20%/20%* ($350) Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD* ($350) 30

31 AD: After Deductible p/p: Per Person This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. Optima Vantage Platinum 25/50 Select CH Optima Vantage Platinum 25/50 Rx Ded Select CH 35/30% Rx Ded Select CH 500/25/20% Rx Ded Select CH Embedded Embedded Embedded Embedded Embedded None None None $500/$1,000 $1,000/$2,000 $2,500/$5,000 $2,500/$5,000 $6,850/$13,700 $6,000/$12,000 $4,500/$9,000 $25 $25 $35 $25 $20 $25 $25 $35 $25 $20 $50 $50 $70 $50 $40 AD $300 $300 30% 20% AD 20% AD $50 $50 30% $50 20% AD $50 $50 30% $50 20% AD $150 $150 30% 20% AD 20% AD 1000/20/20% Rx Ded Select CH 2019 OPTIMA VANTAGE SELECT PLANS $300 copay/day/$1,200 max $300 copay/day/$1,200 max 30% 20% AD 20% AD $250 $250 40% 30% AD 30% AD $50 $50 $70 $50 $40 AD $300 copay/day/$1,200 max $300 copay/day/$1,200 max 30% 20% AD 20% AD $25 $25 $35 $25 $20 $25 $25 30% 20% AD 20% AD no copay required no copay required no copay required no copay required no copay required 0% 0% 0% 0% (Deductible does not apply) 0% (Deductible does not apply) 20% 20% 30% 20% AD 20% AD 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 20% 20% 30% 20% AD 20% AD $500 $500 $500 $450 $450 $10/$40/20%/20%* ($350) Rx p/p Deductible $100 $10/$40 AD/20% AD/20% AD* ($350) Rx p/p Deductible $100 $10/$40 AD/30% AD/30% AD* ($350) Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD* ($350) Rx p/p Deductible $100 $15/$50 AD/20% AD/20% AD ($350*) 31

32 2019 Optima Vantage Select Plans (continued) Plan Name 1000/25/30% Rx Ded Select CH 1500/30/0% Rx Ded Select CH 1500/25/20% Rx Ded Select CH Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family $1,000/$2,000 $1,500/$3,000 $1,500/$3,000 Max Out-of-Pocket Individual/Family $4,000/$8,000 $7,150/$14,300 $4,000/$8,000 Physician Services PCP Office Visit $25 $30 $25 Virtual Consult $25 $30 $25 Specialist Visit $50 AD $60 $50 Outpatient Surgery Outpatient Surgery 30% AD 0% AD 20% AD Outpatient Services Outpatient Diagnostic Procedures & Tests 30% AD $60 20% AD Outpatient Lab Work 30% AD $30 20% AD Advanced Imaging & Testing Procedures 30% AD $300 20% AD Inpatient Services Inpatient Hospital Services 30% AD 0% AD 20% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-network) 40% AD 20% AD 30% AD Urgent Care $50 AD $60 $40 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services 30% AD 0% AD 20% AD Outpatient Office Visits $25 $30 $25 Other Outpatient Visits 30% AD 0% AD 20% AD Employee Assistance Visits Diabetes Treatment Insulin Pumps 0% 0% 0% Pump Infusion Sets & Supplies 30% AD 0% AD 20% AD Testing Supplies Other Covered Services Adult Preventive Vision Exams 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months Chiropractic Care (Spinal Manipulation) 30% AD 0% AD 20% AD Maternity Care $500 0% AD $450 Pharmacy Prescription Drug Coverage Rx p/p Deductible $200 $15/$50 AD/30% AD/30% AD* ($350) Rx p/p Deductible $200 $25/$50 AD/25% AD/25% AD* ($350) Rx p/p Deductible $200 $15/$50 AD/20% AD/20% AD* ($350) 32

33 AD: After Deductible p/p: Per Person This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. 2000/25/30% Select CH 2000/25/30% Rx Ded Select CH 2500/35/0% Rx Ded Select CH Optima Vantage Silver 3000/35/25% Select CH Embedded Embedded Embedded Embedded Embedded $2,000/$4,000 $2,000/$4,000 $2,500/$5,000 $3,000/$6,000 $3,700/$7,400 $4,000/$8,000 $4,000/$8,000 $7,150/$14,300 $7,350/$14,700 $7,500/$15,000 $25 $25 $35 $35 $40 $25 $25 $35 $35 $40 $50 $50 $65 $70 $80 30% AD 30% AD 0% AD 25% AD 20% AD 30% AD 30% AD 0% AD 25% AD 20% AD 30% AD 30% AD 0% AD 25% AD 20% AD 30% AD 30% AD 0% AD 25% AD 20% AD 30% AD 30% AD 0% AD 25% AD 20% AD Optima Vantage Silver 3700/40/20% Rx Ded Select CH 2019 OPTIMA VANTAGE SELECT PLANS 40% AD 40% AD 20% AD 35% AD 30% AD $50 $50 0% AD $70 $80 30% AD 30% AD 0% AD 25% AD 20% AD $25 $25 $35 $35 $40 30% AD 30% AD 0% AD 25% AD 20% AD 0% 0% 0% 0% 0% 30% AD 30% AD 0% AD 25% AD 20% AD 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 30% AD 30% AD 0% AD 25% AD 20% AD $500 $500 $500 25% AD 20% AD $15/$50/30%/30%* ($350) Rx p/p Deductible $100 $15/$50 AD/30% AD/30% AD* ($350) Rx p/p Deductible $200 $15/$50 AD/25% AD/25% AD* ($350) $15 AD/$50 AD/25% AD/ 25% AD* ($350) Rx p/p Deductible $150 $15 AD/$50 AD/20% AD/ 20% AD* ($350) 33

34 2019 Optima Vantage Select (continued) and Vantage Select Equity Plans Plan Name Optima Vantage Silver 5000/40/20% Select CH Optima Vantage Bronze 6600/30% Select CH Optima Vantage Equity Silver 2700/10% Select CH Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family $5,000/$10,000 $6,600/$13,200 $2,700/$5,400 Max Out-of-Pocket Individual/Family $7,350/$14,700 $7,800/$15,600 $6,000/$12,000 Physician Services PCP Office Visit $40 $45 for first 2 visits; then 30% AD 10% AD Virtual Consult $40 $45 for first 2 visits; then 30% AD 10% AD Specialist Visit $80 30% AD 10% AD Outpatient Surgery Outpatient Surgery 20% AD 30% AD 10% AD Outpatient Services Outpatient Diagnostic Procedures & Tests 20% AD 30% AD 10% AD Outpatient Lab Work 20% AD 30% AD 10% AD Advanced Imaging & Testing Procedures 20% AD 30% AD 10% AD Inpatient Services Inpatient Hospital Services 20% AD 30% AD 10% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-network) 30% AD 40% AD 20% AD Urgent Care $80 30% AD 10% AD Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services 20% AD 30% AD 10% AD Outpatient Office Visits $40 10% 10% AD Other Outpatient Visits 20% AD 30% AD 10% AD Employee Assistance Visits Diabetes Treatment no copay required no copay required Insulin Pumps 0% 0% 10% AD Pump Infusion Sets & Supplies 20% AD 30% AD 10% AD no copay required Testing Supplies 10% AD Other Covered Services Adult Preventive Vision Exams 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months Chiropractic Care (Spinal Manipulation) 20% AD 30% AD 10% AD Maternity Care 20% AD 30% AD 10% AD Pharmacy Prescription Drug Coverage n/a $10/$40/20%/20%* ($350) 30% AD/30% AD/30% AD/ 30% AD* ($350) $15 AD/$50 AD/10% AD/ 10% AD* ($350) 34

35 AD: After Deductible p/p: Per Person This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. Optima Vantage Equity Silver 3000/20% Select CH Optima Vantage Equity Silver 4000/0% Select CH Optima Vantage Equity Bronze 5400/40% Select CH Embedded Embedded Embedded Embedded $3,000/$6,000 $4,000/$8,000 $5,400/$10,800 $6,500/$13,000 $4,800/$9,600 $6,650/$13,300 $6,650/$13,300 $6,650/$13,300 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 30% AD 20% AD 50% AD 20% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD for each individual covered; for each individual covered; for each individual covered; 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD Optima Vantage Equity Bronze 6500/0% Select CH for each individual covered; 2019 OPTIMA VANTAGE SELECT AND VANTAGE EQUITY SELECT 20% AD 0% AD 40% AD 0% AD 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 20% AD 0% AD 40% AD 0% AD 20% AD 0% AD 40% AD 0% AD $15 AD/$50 AD/20% AD/20% AD* ($350) 0% AD/0% AD/0% AD/0% AD $15 AD/$50 AD/40% AD/40% AD* ($350) 0% AD/0% AD/0% AD/0% AD 35

36 Looking for Even More Options? Optima BusinessEDGE Creates Flexibility and Savings BusinessEDGE is a level-funded alternative for qualifying groups with total enrolled employees. This underwritten product can save healthy groups money compared to fully insured plans. Your maximum exposure is funded with consistent monthly premiums to cover claims, stop-loss coverage, and administration. If actual claims expenses are lower than expected, you may receive money back! NEW in BusinessEDGE for 2019 The Out of Area (OOA) Dependent Program offers enrolled dependent children access to care outside of the Optima Health service area. They re able to receive covered services from PHCS/Multiplan providers. Pre-Authorization still applies when necessary, and emergency services will continue to be covered as in-network. Preventive Vision Exam at 0% for one visit every 12-months. BusinessEDGE Equity plans now have a pharmacy option that provides access to preventive drugs before meeting the medical deductible. 36

37 We choose Optima Health because... their service is simply beyond compare. ADS, Inc. How does the BusinessEDGE plan work? 1. Employer pays a fixed monthly payment per enrolled employee that includes monthly estimated claims, stop-loss premium and administrative fee. estimated claims administrative fees stop-loss premium 2. Optima Health processes claims, issues ID cards, provides customer service, and sets up the health plan provider network. 3. Stop-loss insurance limits the risk for excessive medical claims. 4. At the end of the 12-month contract, and an additional 12-month run-out period, the claims fund is evaluated against actual paid claims. A refund may be provided. Optima BusinessEDGE level-funded group plans are administered but not underwritten by Sentara Health Plan. Stop-Loss Insurance product is offered by Optima Health Insurance Company SMALL GROUP GUIDE 37

38 2019 Optima BusinessEDGE Vantage Plans Plan Name Optima Vantage 20/40 Optima Vantage 25/50 Optima Vantage 25/30% Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family None None None Max Out-of-Pocket Individual/Family $2,500/$5,000 $3,000/$6,000 $3,000/$6,000 Physician Services PCP Office Visit $20 $25 $25 Virtual Consult $20 $25 $25 Specialist Visit $40 $50 $50 Outpatient Surgery Outpatient Surgery $200 $300 30% Outpatient Services Outpatient Diagnostic Procedures & Tests $40 $50 30% Outpatient Lab Work $40 $50 30% Advanced Imaging & Testing Procedures $150 $150 30% Inpatient Services Inpatient Hospital Services $200 copay/day/$1,000 max $250 copay/day/$1,250 max 30% Emergency & Urgent Care Services Emergency Services (In or Out-of-network) $250 $250 30% Urgent Care $40 $50 $50 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services $200 copay/day/$1,000 max $250 copay/day/$1,250 max 30% Outpatient Office Visits $20 $25 $25 Other Outpatient Visits $20 $25 30% Employee Assistance Visits Diabetes Treatment Insulin Pumps 0% 0% 0% Pump Infusion Sets and Supplies 20% 20% 20% Testing Supplies 20% 20% 20% Other Covered Services Preventive Vision Exams 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months Chiropractic Care (Spinal Manipulation) $20 $25 30% Maternity Care $450 $500 $500 Pharmacy Prescription Drug Coverage - Default Prescription Drug Coverage - High Option Prescription Drug Coverage - Low Option Smoking Cessation $10/$30/$50 or 20%*/20%* ($250) Rx p/p Deductible $50 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) n/a $10/$30/$50 or 20%*/20%* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/$75 AD or 20% AD* ($250) Rx p/p Deductible $50 $10 AD/$40 AD/$60 or 20%*/20% AD* ($250) $10/$30/$50 or 20%*/20%* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/$75 AD or 20% AD* ($250) Covered Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider. 38

39 AD: After Deductible p/p: Per Person This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. Optima Vantage 500/20/20% Optima Vantage 1000/25/30% Optima Vantage 2000/25/30% Optima Vantage 3000/30/0% Optima Vantage 4000/30/0% Embedded Embedded Embedded Embedded Embedded $500/$1,500 $1,000/$2,000 $2,000/$4,500 $3,000/$6,000 $4,000/$8,000 $3,500/$7,000 $3,500/$7,000 $3,500/$7,000 $5,500/$11,000 $6,500/$13,000 $20 $25 $25 $30 $30 $20 $25 $25 $30 $30 $40 $50 $50 $60 $60 20% AD 30% AD 30% AD 0% AD 0% AD 20% AD 30% AD 30% AD 0% AD 0% AD 20% AD 30% AD 30% AD 0% AD 0% AD 20% AD 30% AD 30% AD 0% AD 0% AD 20% AD 30% AD 30% AD 0% AD 0% AD 20% AD 30% AD 30% AD $250 $250 $40 $50 $50 $75 $75 20% AD 30% AD 30% AD 0% AD 0% AD 2019 OPTIMA BUSINESSEDGE VANTAGE PLANS $20 $25 $25 $30 $30 20% 30% 30% 10% 10% 0% 0% 0% 0% 0% 20% AD 20% AD 20% AD 0% AD 0% AD 20% AD 20% AD 20% AD 0% AD 0% AD 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 20% AD 30% AD 30% AD 0% AD 0% AD $450 $500 $500 0% AD 0% AD Rx p/p Deductible $75 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Rx p/p Deductible $75 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) $10/$30/$50 or 20%*/20%* ($250) $10/$30/$50 or 20%*/20%* ($250) $10/$30/$50 or 20%*/20%* ($250) $10/$30/$50 or 20%*/20%* ($250) $10/$30/$50 or 20%*/20%* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) n/a n/a n/a Covered Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider. 39

40 2019 Optima BusinessEDGE Vantage Equity Plans Plan Name Optima Vantage Equity 2700/30% Optima Vantage Equity 3000/0% Embedded/Non-Embedded Embedded Embedded Deductible Individual/Family (No 4th Quarter Deductible Carryover on Equity Plans) $2,700/$5,400 $3,000/$6,000 Max Out-of-Pocket Individual/Family $5,500/$11,000 $4,000/$8,000 Physician Services PCP Office Visit 30% AD 0% AD Virtual Consult 30% AD 0% AD Specialist Visit 30% AD 0% AD Outpatient Surgery Outpatient Surgery 30% AD 0% AD Outpatient Services Outpatient Diagnostic Procedures & Tests 30% AD 0% AD Outpatient Lab Work 30% AD 0% AD Advanced Imaging & Testing Procedures 30% AD 0% AD Inpatient Services Inpatient Hospital Services 30% AD 0% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-network) 30% AD 10% AD Urgent Care 30% AD 0% AD Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services 30% AD 0% AD Outpatient Office Visits 30% AD 0% AD Other Outpatient Visits 30% AD 0% AD Employee Assistance Visits Diabetes Treatment for each individual covered; for each individual covered; Insulin Pumps 30% AD 0% AD Pump Infusion Sets and Supplies 30% AD 0% AD Testing Supplies 30% AD 0% AD Other Covered Services Preventive Vision Exams 0% for 1 visit every 12 months 0% for 1 visit every 12 months Chiropractic Care (Spinal Manipulation) 30% AD 0% AD Maternity Care 30% AD 0% AD Pharmacy Prescription Drug Coverage - Default Prescription Drug Coverage - High Option Prescription Drug Coverage - Low Option $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Prev BD, $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) n/a $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Prev BD, $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) n/a Smoking Cessation Covered Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider. 40

41 AD: After Deductible p/p: Per Person Prev BD: preventive drugs before deductible This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Please see plan-specific summary for more information. All values reflect in-network coverage. Coinsurance amounts represent the percentage the member pays. Optima Vantage Equity 3000/10% Optima Vantage Equity 4000/20% Optima Vantage Equity 5000/0% Embedded Embedded Embedded $3,000/$6,000 $4,000/$8,000 $5,000/$10,000 $4,500/$9,000 $5,950/$11,900 $6,550/$13,100 10% AD 20% AD $30 AD 10% AD 20% AD $30 AD 10% AD 20% AD $60 AD 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD 10% AD 20% AD 20% AD 10% AD 20% AD 20% AD 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD 2019 OPTIMA BUSINESSEDGE VANTAGE EQUITY PLANS 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD 0% for 1 visit every 12 months 0% for 1 visit every 12 months 0% for 1 visit every 12 months 10% AD 20% AD 0% AD 10% AD 20% AD 0% AD $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Prev BD, $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Prev BD, $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Prev BD, $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) n/a n/a n/a Covered Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider. 41

42 2019 Optima BusinessEDGE Vantage Design Plans (continued) and BusinessEDGE POS Plans Plan Name Optima Vantage Design 2500/10% Optima Vantage Design 3000/20% Embedded/Non-Embedded Embedded Embedded Deductible Individual/Family (No 4th Quarter Deductible Carryover on Design Plans) $2,500/$5,000 $3,000/$6,000 Max Out-of-Pocket Individual/Family $4,000/$8,000 $5,000/$10,000 Physician Services PCP Office Visit 10% AD 20% AD Virtual Consult 10% AD 20% AD Specialist Visit 10% AD 20% AD Outpatient Surgery Outpatient Surgery 10% AD 20% AD Outpatient Services Outpatient Diagnostic Procedures & Tests 10% AD 20% AD Outpatient Lab Work 10% AD 20% AD Advanced Imaging & Testing Procedures 10% AD 20% AD Inpatient Services Inpatient Hospital Services 10% AD 20% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-network) 10% AD 20% AD Urgent Care 10% AD 20% AD Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services 10% AD 20% AD Outpatient Office Visits 10% AD 20% AD Other Outpatient Visits 10% AD 20% AD Employee Assistance Visits Diabetes Treatment for each individual covered; Insulin Pumps 0% 0% Pump Infusion Sets and Supplies 10% AD 20% AD Testing Supplies 10% AD 20% AD Other Covered Services for each individual covered; Preventive Vision Exams 0% for 1 visit every 12 months 0% for 1 visit every 12 months Chiropractic Care (Spinal Manipulation) 10% AD 20% AD Maternity Care 10% AD 20% AD Pharmacy Prescription Drug Coverage - Default Prescription Drug Coverage - High Option Prescription Drug Coverage - Low Option Smoking Cessation $10/$40/$60 or 20%*/20%* ($250) $10/$40/$60 or 20%*/20%* ($250) n/a n/a Covered Food and Drug Administration (FDA)- approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider. n/a n/a Covered Food and Drug Administration (FDA)- approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider. 42

43 AC: Allowable Charge AD: After Deductible p/p: Per Person Prev BD: preventive drugs before deductible This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Out-of-network (OON) amounts may vary. Please see plan-specific summary for more information. Coinsurance amounts represent the percentage the member pays. Plan Name Optima POS 1000/25/20% Optima POS Equity 2700/10% Embedded/Non-Embedded Embedded Embedded Deductible Individual/Family (In Network; No 4th Quarter Deductible Carryover on Equity) Deductible Individual/Family (Out-of-network; No 4th Quarter Deductible Carryover on Equity) $1,000/$2,000 $2,700/$5,400 $1,250/$2,500 $5,400/$10,800 Max Out-of-Pocket Individual/Family (In Network) $3,750/$7,000 $5,500/$11,000 Max Out-of-Pocket Individual/Family (Out-of-network) $8,000/$16,000 $11,000/$22,000 Out-of-Network Coinsurance 40% AD/AC 50% AD/AC Physician Services PCP Office Visit $25 10% AD Virtual Consult (No Out-of-Network Coverage) $25 10% AD Specialist Visit $40 10% AD Outpatient Surgery Outpatient Surgery 20% AD 10% AD Outpatient Services Outpatient Diagnostic Procedures & Tests 20% AD 10% AD Outpatient Lab Work 20% AD 10% AD Advanced Imaging & Testing Procedures 20% AD 10% AD Inpatient Services Inpatient Hospital Services 20% AD 10% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-network) 20% AD 10% AD Urgent Care $40 10% AD Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services 20% AD 10% AD Outpatient Office Visits $25 10% AD Other Outpatient Visits 20% 10% AD Employee Assistance Visits Diabetes Treatment Insulin Pumps 0% 10% AD Pump Infusion Sets & Supplies 20% AD 10% AD Testing Supplies 20% AD 10% AD Other Covered Services Preventive Vision Exams 0% for 1 visit every 12 months In Network. Max reimbursement of $30 Out-of-Network for eye exam only. Chiropractic Care (Spinal Manipulation) 20% AD 10% AD Maternity Care 20% AD 10% AD Pharmacy Prescription Drug Coverage - Default Prescription Drug Coverage - High Option Prescription Drug Coverage - Low Option Smoking Cessation Rx p/p Deductible $100 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) $10/$30/$50 or 20%*/20%* ($250) Prev BD, $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/$60 AD or 20% AD*/20% AD* ($250) Covered Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider. n/a 2019 OPTIMA BUSINESSEDGE VANTAGE DESIGN PLANS AND BUSINESSEDGE POS PLANS 43

44 2019 Optima BusinessEDGE Plus Plans Plan Name Optima Plus 500/25/20% Optima Plus 1500/25/20% Optima Plus 1750/30/30% 44 Embedded/Non-Embedded Embedded Embedded Embedded Deductible Individual/Family (In Network; No 4th Quarter Deductible Carryover on Equity or Design Plans) Deductible Individual/Family (Out-of-network; No 4th Quarter Deductible Carryover on Equity or Design Plans) $500/$1,000 $1,500/$3,000 $1,750/$3,500 $750/$1,500 $1,750/$3,500 $2,000/$4,000 Max Out-of-Pocket Individual/Family (In Network) $3,000/$6,000 $4,500/$9,000 $5,500/$10,000 Max Out-of-Pocket Individual/Family (Out-of-network) $8,000/$16,000 $9,500/$19,000 $10,500/$21,000 Out-of-Network Coinsurance 40% AD/AC 40% AD/AC 50% AD/AC Physician Services PCP Office Visit $25 $25 $30 Virtual Consult (No Out-of-Network Coverage) $25 $25 $30 Specialist Visit $40 $40 $30 Outpatient Surgery Outpatient Surgery 20% AD 20% AD 30% AD Outpatient Services Outpatient Diagnostic Procedures & Tests 20% AD 20% AD 30% AD Outpatient Lab Work 20% AD 20% AD 30% AD Advanced Imaging & Testing Procedures 20% AD 20% AD 30% AD Inpatient Services Inpatient Hospital Services 20% AD 20% AD 30% AD Emergency & Urgent Care Services Emergency Services (In or Out-of-Network) 20% AD 20% AD 30% AD Urgent Care $40 $40 $30 Mental/Behavioral Health & Substance Use Disorder Services Inpatient Services 20% AD 20% AD 30% AD Outpatient Office Visits $25 $25 $30 Other Outpatient Visits 20% 20% 30% Employee Assistance Visits Diabetes Treatment Insulin Pumps 0% 0% 0% Pump Infusion Sets and Supplies 20% AD 20% AD 20% AD Testing Supplies 20% AD 20% AD 20% AD Other Covered Services Preventive Vision Exams 0% for 1 visit every 12 months In Network. Max reimbursement of $30 Out-of-Network for eye exam only Chiropractic Care (Spinal Manipulation) 20% AD 20% AD 30% AD Maternity Care 20% AD 20% AD 30% AD Pharmacy Prescription Drug Coverage - Default Prescription Drug Coverage - High Option Prescription Drug Coverage - Low Option Smoking Cessation Rx p/p Deductible $75 $10 AD/$40 AD/ $60 AD or 20% AD*/20% AD* ($250) $10/$30/ $50 or 20%*/20%* ($250) Rx p/p Deductible $150 $10 AD/$40 AD/ $60 AD or 20% AD/20% AD Rx p/p Deductible $150 $10 AD/$40 AD/ $60 AD or 20% AD*/20% AD* ($250) $10/$30/ $50 or 20%*/20%* ($250) Rx p/p Deductible $75 $10 AD/$40 AD/ $60 AD or 20% AD/20% AD* ($250) $10/$30/ $50 or 20%*/20%* ($250) n/a Rx p/p Deductible $150 $10 AD/$40 AD/ $60 AD or 20% AD/20% AD Covered Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider.

45 AC: Allowable Charge Prev BD: preventive drugs before deductible AD: After Deductible p/p: Per Person This is a summary of the standard covered expenses. Exclusions and Limitations apply. Additional benefits may be available. Out-of-network (OON) amounts may vary. Please see plan specific summary for more information. Coinsurance amounts represent the percentage the member pays. Optima Plus Equity 3000/0% Optima Plus Equity 3000/10% Optima Plus Equity 4000/20% Optima Plus Design 2500/10% Embedded Embedded Embedded Embedded $3,000/$6,000 $3,000/$6,000 $4,000/$8,000 $2,500/$5,000 $4,000/$8,000 $4,000/$8,000 $5,500/$10,500 $3,500/$7,000 $4,000/$8,000 $4,500/$9,000 $5,950/$11,900 $4,000/$8,000 $8,000/$16,000 $8,000/$16,000 $10,000/$20,000 $7,000/$14,000 30% AD/AC 30% AD/AC 40% AD/AC 30% AD/AC 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 2019 OPTIMA BUSINESSEDGE PLUS PLANS 10% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD for each individual covered; for each individual covered; for each individual covered; for each individual covered; 0% AD 10% AD 20% AD 0% 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD 0% for 1 visit every 12 months In Network. Max reimbursement of $30 Out-of-Network for eye exam only 0% AD 10% AD 20% AD 10% AD 0% AD 10% AD 20% AD 10% AD $10 AD/$40 AD/$60 AD or 20% AD*/ 20% AD* ($250) Prev BD, $10 AD/$40 AD/ $60 AD or 20% AD*/ 20% AD* ($250) $10 AD/$40 AD/$60 AD or 20% AD*/ 20% AD* ($250) Prev BD, $10 AD/$40 AD/ $60 AD or 20% AD*/ 20% AD* ($250) $10 AD/$40 AD/ $60 AD or 20% AD*/ 20% AD* ($250) Prev BD, $10 AD/$40 AD/ $60 AD or 20% AD*/ 20% AD* ($250) n/a n/a n/a n/a $10/$40/$60 or 20%*/20%* ($250) n/a Covered Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) are limited to two 90-day treatment regimens per contract year when prescribed by a healthcare provider. 45

46 Service Description and Requirements PHYSICIAN SERVICES There is an additional Copay or Coinsurance for outpatient Habilitative and Rehabilitative therapy and services, injectable and infused medications, allergy care, testing and serum, outpatient advanced imaging procedures, and sleep studies done during an office visit. Pre-Authorization is required for in-office surgery. OUTPATIENT SERVICES Outpatient Surgery Pre-Authorization is required. Copay or Coinsurance applies to services provided in a free-standing ambulatory surgery center or hospital outpatient surgical facility. Outpatient Diagnostic Procedures & Tests Copay or Coinsurance will apply when a procedure is performed in a free-standing outpatient facility or lab, or a hospital outpatient facility or lab. Diagnostic tests include: X-rays, Ultrasound, and Doppler Studies. Outpatient Lab Work Outside of physician office visit Advanced Imaging & Testing Procedures MRI, MRA, PET, CT, CTA, MRS, SPECT, Nuclear Cardiology, Sleep Studies. Pre-Authorization is required for all procedures except MRS, SPECT, and Nuclear Cardiology. Copay or Coinsurance applies to procedures done in a Physician s office, a free-standing outpatient facility, or a hospital outpatient facility. EMERGENCY SERVICES Pre-Authorization is not required. Includes Emergency Services, Physician Services, Advanced Diagnostic Imaging, such as MRIs, and CT scans, and Other Facility Charges, such as diagnostic x-ray and lab services, and medical supplies, provided in an emergency department In Network or Out-of-Network. MENTAL/BEHAVIORAL HEALTH & SUBSTANCE USE DISORDER SERVICES Includes inpatient and outpatient services for the treatment of mental health and substance use disorder. Pre-Authorization is required for Inpatient Services, partial hospitalization services, Intensive Outpatient Program (IOP), Electro-Convulsive Therapy, and Transcranial Magnetic Stimulation (TMS). Other Outpatient Visits Includes Hospital Outpatient and Free-standing Outpatient Centers DIABETES TREATMENT Coverage includes benefits for equipment, supplies and in-person outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin-using diabetes if prescribed by a healthcare professional legally authorized to prescribe such items under law. Equipment and supplies under this benefit are not considered durable medical equipment. An annual diabetic eye exam is covered from an Optima Health Plan Provider or a participating [EyeMed] Provider at the applicable office visit Copay or Coinsurance amount. Insulin Pumps Pre-Authorization required Pump Infusion Sets and Supplies Pre-Authorization required Testing Supplies Includes test strips, lancets, lancet devices, blood glucose monitors and control solution. MATERNITY CARE Pre-Authorization is required for prenatal services. Includes prenatal, delivery, postpartum services, and home health visits. The inpatient hospital Copay or Coinsurance is also applied. CHIROPRACTIC CARE Optima Health contracts with American Specialty Health Group (ASH) to administer this benefit. Pre-Authorization is required by ASH for all services. ALLOWABLE CHARGE (AC) Allowable Charge (AC): the amount Optima Health determines should be paid to a provider for a covered service. When you use in-network benefits from plan providers, the allowable charge is the provider s contracted rate with Optima Health or the provider s actual charge for the service; whichever is less. Plan providers accept this amount as payment in full. Optima Health is the trade name of Optima Health Plan. Optima Health Insurance Company, Optima Health Group, Inc. and Sentara Health Plans, Inc. Optima Vantage, POS, Direct, and Select plans are underwritten by Optima Health Plan. Optima Plus (PPO) products are underwritten by Optima Health Insurance Company. Level-funded BusinessEDGE plans are administered, but not underwritten by, Sentara Health Plans, Inc. Stop-Loss policies are offered and underwritten by Optima Health Insurance Company. All Optima Health plans have benefit exclusions and limitations and terms under which the policy may be continued in force or discontinued. Wellness and rewards programs are administered by Sentara Health Plans, Inc. and are not covered benefits under any Optima Health plan. Value added benefits are not covered benefits under any Optima Health plan. For costs and complete details of coverage, please call your broker or Optima Health at or visit optimahealth.com. 46

47 Choose Optima Health in 2019 More Options More Innovation Same Exceptional Service Virginians Serving Virginians 2019 SMALL GROUP GUIDE 47

48 BROKER SERVICES 8 a.m. to 5 p.m. EST Monday through Friday brokerservices@optimahealth.com MAIN OFFICE VIRGINIA BEACH 4417 Corporation Lane, Virginia Beach, VA Phone: Toll-Free: Fax: PENINSULA Jefferson Avenue, Suite 200, Newport News, VA Phone: Toll-Free: Fax: RICHMOND 1604 Santa Rosa Road, Suite 100, Richmond, VA Phone: Toll-Free: Fax: Toll-Free Fax: ROANOKE 129 Campbell Avenue, SE, Roanoke, VA Phone: Toll-Free: Fax: Rev. 8/24/2018