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<br />A brief summary of the CareAccess plan design is shown below: <br /> <br />General Provisions Hiah Ootion Low Ontion <br />Is a PCP election/referral required Yes Yes <br />Annual Benefit Maximum (Outpatient Onlv) $25,000 $25,000 <br />Annual deductible (ifF) N/A N/A <br />Annual Out-of-Pocket Max (excludina deductible) N/A N/A <br />Hospital Admission Benefit $500/day up to 100 $500/day up to 100 <br />(Provided through Markel) days/confinement days/confinement <br />Plan Coinsurance None None <br />Inpatient Surgery Benefit <br />(Provided throuah Markel) $2,000/1 per year $2,000/1 oer year <br />Outpatient Services <br />Primary Care Physician office visit 100% after $10 copay 100% after $20 cooay <br /> Included in PCP office Included in PCP office <br />Immunizations visit cooav visit copay <br />Well Child Care 100% after $10 copay 100% after $20 cooav <br />Annual Physical 100% after ap~ cooay 100% after aDo CODay <br />GYN visit $25 soecialist $35 soecialist <br />Mammograms $25 soecialist $35 soecialist <br />Specialist Office Visit 100% after $25 cooay 100% after $35 copav <br />Maternity Care (Pre and Post Natall 100% after $25 cooav 100% after $35 cooay <br /> $750 max after $100 $750 max after $200 <br />Outpatient Surgery' cooav/eoisode cooav/episode <br />Oral Suraery N/A N/A <br />Emergency Room (in-area hospital) $300 (1 for injury/1 for $300 (1 for injury/1 for <br />siCkness/year) sickness/year) <br />Prescription DrullS" <br />Retail Generic I Formulary Brand / Non- <br />Formulary $7/25/25 $15/35/35 <br />Mail Generic I Formulary Brand I Non-Formulary N/A N/A <br /> <br />*In addition, Markel pays for 1 outpatient surgery per calendar year at $800 <br />"Plan pays maximum $1,200 per year, maximum $100 per month, no carry over. Monthly limit not <br />combined with specialty injectibles limIt or immunization limits <br /> <br />R <br />E <br />V <br /> <br />H <br />H <br /> <br />s <br />E <br />D <br /> <br />R <br /> <br />H <br /> <br />E <br />D <br /> <br />H <br /> <br /> <br />D <br /> <br />Collective bargaining will be conducted with each union regarding plan design and <br />contribution levels. <br /> <br />Page 6 of 8 <br />