MEDICAL COVERAGE OPTIONS: January 1, 2018 to December …

1 MEDICAL COVERAGE options : January 1, 2021 to December 31, 2021 COMMUNITY BLUECOMMUNITY # #2In-NetworkOut-of-NetworkIn-NetworkOut- of-NetworkIn-NetworkOut-of-NetworkCosts PremiumSingle - $7,606 Single - $6,957 Two Person - $17,641 Two Person - $15,680 Family - $22,821 Family - $20,870 Employee Premium Contribution20%10%Deductible: Annual $250 for one member $500 for the family (when two or more members are covered under your contract) each calendar year $500 for one member $1,000 for the family (when two or more members are covered under your contract) each calendar year Note: Out-of-network deductible amounts also count toward the in-network deductible $500 for one member $1,000 for the family (when two or more members are covered under your contract) each calendar year $1,000 for one member $2,000 for the family (when two or more members are covered under your contract) each calendar year Note: Out-of-network deductible amounts also count toward the in-network deductible $2,000 for a one-person contract $4,000 for a family contract (2 or more members) each calendar year $4,000 for a one-person contract $8,000 for a familycontract (2 or more members) each calendar yearCoinsurance amounts (percent copays) Note: Coinsurance amounts apply once the deductible has been met.

2 50% of approved amount for private duty nursing care 0% coinsurance for most other covered services 50% of approved amount for private duty nursing care 40% of approved amount for mental health and substance abuse treatment 40% of approved amount for most other covered services 50% of approved amount for private duty nursing care 10% of approved amount for most other covered services (coinsurance waived for covered services performed in an in-network physician's office) 50% of approved amount for private duty nursing care 40% of approved amount for mental health and substance abuse treatment 40% of approved amount for most other covered services20% of approved amount for most covered services40% of approved amount for most covered servicesSIMPLY BLUE Health Savings Account Single - $4,918 Two Person - $11,805 Family - $14,7555%9/9/20201 MEDICAL COVERAGE options : January 1, 2021 to December 31, 2021 COMMUNITY BLUECOMMUNITY # #2In-NetworkOut-of-NetworkIn-NetworkOut- of-NetworkIn-NetworkOut-of-NetworkSIMPLY BLUE Health Savings Account Coinsurance Maximum$0 for most covered services $3,000 for one member $6,000 for two or more members each calendar year Note: Out-of-network cost sharing amounts also apply toward the in-network out-of-pocket maximum.

3 $1,000 for one member $2,000 for two or more members each calendar year $3,000 for one member $6,000 for two or more members each calendar year Note: Out-of-network cost sharing amounts also apply toward the in-network out-of-pocket maximum. $500 for a one-person $1,000 for a family contract (2 or more members) each calendar year $1,000 for a one-person $2,000 for a family contract (2 or more members) each calendar yearFlat dollar copays Blue Cross Online Visits - $ copay for PPO #1 and #2 (see Benefits Handbook for more information) $10 copay for office visits and office consultations $10 copay for chiropractic services and osteopathic manipulative therapy $100 copay for emergency room visits$100 copay for emergency room visits $20 copay for office visits and office consultations $20 copay for chiropractic services and osteopathic manipulative therapy $100 copay for emergency room visits$100 copay for emergency room visitsSee "Prescription Drugs" sectionSee "Prescription Drugs" sectionAnnual out-of-pocket maximums - applies to deductibles, copays and coinsurance amounts for all covered services - including cost sharing amounts for prescription drugs.

4 $6,350 for one member $12,700 for two or more members each calendar year $12,700 for one member $25,400 for two or more members each calendar year Note: Out-of-network cost sharing amounts also apply toward the in-network out-of-pocket maximum. $6,350 for one member $12,700 for two or more members each calendar year $12,700 for one member $25,400 for two or more members each calendar year Note: Out-of-network cost sharing amounts also apply toward the in-network out-of-pocket maximum. $2,500 for a one-person $5,000 for a family contract (2 or more members) each calendar year $5,000 for a one-person $10,000 for a family contract (2 or more members) each calendar yearLifetime dollar maximumNoneNoneNone9/9/20202 MEDICAL COVERAGE options : January 1, 2021 to December 31, 2021 COMMUNITY BLUECOMMUNITY # #2In-NetworkOut-of-NetworkIn-NetworkOut- of-NetworkIn-NetworkOut-of-NetworkSIMPLY BLUE Health Savings Account Preventative Care Services One per Member per calendar yearHealth Maintenance Exam -- includes chest x-ray, EKG.

5 Cholesterol screening and other select lab proceduresCovered - 100%Not CoveredCovered - 100%Not CoveredCovered - 100%Not CoveredGynecological ExamCovered - 100%Not CoveredCovered - 100%Not CoveredCovered - 100%Not CoveredPap Smear Screening - laboratory and pathology servicesCovered - 100%Not CoveredCovered - 100%Not CoveredCovered - 100%Not CoveredVoluntary Sterilizations for femalesCovered - 100%Covered - 60% after deductibleCovered - 100%Covered - 60% after deductibleCovered - 100%Covered - 60% after deductiblePrescription contraceptive devices - includes insertion and removal of an intrauterine device by a licensed physicianCovered - 100%Covered - 100% after deductibleCovered - 100%Covered - 100% after deductibleCovered - 100%Covered - 60% after deductibleContraceptive injectionsCovered - 100%Covered - 60% after deductibleCovered - 100%Covered - 60% after deductibleCovered - 100%Covered - 60% after deductibleWell-Baby and Child CareCovered - 100%Not CoveredCovered - 100%Not CoveredCovered - 100%Not Covered9/9/20203 MEDICAL COVERAGE options : January 1, 2021 to December 31, 2021 COMMUNITY BLUECOMMUNITY # #2In-NetworkOut-of-NetworkIn-NetworkOut- of-NetworkIn-NetworkOut-of-NetworkSIMPLY BLUE Health Savings Account Preventative Care Services cont.

6 Immunizations - Adult and childhood immunizations as recommended by the Advisory Committee on Immunization practices. Note: Immunizations for travel to foreign countries are not - 100%Not CoveredCovered - 100%Not CoveredCovered - 100%Not CoveredFecal Occult Blood ScreeningCovered - 100%Not CoveredCovered - 100%Not CoveredCovered - 100%Not CoveredFlexible Sigmoidoscopy Exam Covered - 100%Not CoveredCovered - 100%Not CoveredCovered - 100%Not CoveredProstate Specific Antigen (PSA) ScreeningCovered - 100%Not CoveredCovered - 100%Not CoveredCovered - 100%Not CoveredRoutine mammogram and related readingCovered - 100%Note: Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and - 60% after deductibleNote: Out-of-network readings and interpretations are payable only when the screening mammogram itself is performed by a in-network - 100%Note: Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and - 60% after deductibleNote: Out-of-network readings and interpretations are payable only when the screening mammogram itself is performed by a in-network - 100%Note: Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and - 60% after deductibleNote: Out-of-network readings and interpretations are payable only when the screening mammogram itself is performed by a in-network COVERAGE options : January 1, 2021 to December 31, 2021 COMMUNITY BLUECOMMUNITY # #2In-NetworkOut-of-NetworkIn-NetworkOut- of-NetworkIn-NetworkOut-of-NetworkSIMPLY BLUE Health Savings Account Preventative Care Services cont.

7 Colonoscopy - routine Covered - 100% once annuallyNote: Subsequent colonoscopies performed during the same calendar year are subject to your deductible and - 60% after deductibleCovered - 100% once annuallyNote: Subsequent colonoscopies performed during the same calendar year are subject to your deductible and - 60% after deductibleCovered - 100% once annuallyCovered - 60% after deductiblePhysician ServicesOffice VisitsCovered - $10 copayCovered - 60% after deductibleCovered - $20 copayCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleOutpatient and Home VisitsCovered - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleOffice ConsultationsCovered - $10 copayCovered - 60% after deductibleCovered - $20 copayCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleUrgent Care VisitsCovered - $10 copayCovered - 60% after deductibleCovered - $20 copayCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductible9/9/20205 MEDICAL

8 COVERAGE options : January 1, 2021 to December 31, 2021 COMMUNITY BLUECOMMUNITY # #2In-NetworkOut-of-NetworkIn-NetworkOut- of-NetworkIn-NetworkOut-of-NetworkSIMPLY BLUE Health Savings Account Emergency MEDICAL CareHospital Emergency RoomCovered - $100 copay, waived if admitted or for an accidental injuryCovered - $100 copay, waived if admitted or for an accidental injuryCovered - $100 copay, waived if admitted or for an accidental injuryCovered - $100 copay, waived if admitted or for an accidental injuryCovered - 80% after deductibleCovered - 80% after deductibleAmbulance Services - medically necessaryCovered - 100% after deductibleCovered - 100% after deductibleCovered - 90% after deductibleCovered - 90% after deductibleCovered - 80% after deductibleCovered - 80% after deductibleDiagnostic ServicesLaboratory and Pathology TestsCovered - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleDiagnostic Tests and X-raysCovered - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleTherapeutic RadiologyCovered - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60%

9 After deductibleMaternity ServicesPrenatal care visitsCovered - 100%Covered - 60% after deductibleCovered - 100%Covered - 60% after deductibleCovered - 100% after deductibleCovered - 60% after deductiblePostnatal care visitCovered - 100%Covered - 60% after deductibleCovered - 100%Covered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductible9/9/20206 MEDICAL COVERAGE options : January 1, 2021 to December 31, 2021 COMMUNITY BLUECOMMUNITY # #2In-NetworkOut-of-NetworkIn-NetworkOut- of-NetworkIn-NetworkOut-of-NetworkSIMPLY BLUE Health Savings Account Maternity Services and Nursery Care - Includes covered services provided by a certified nurse - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleHospital ServicesSemi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies, Specialty Care Units Note.

10 Unlimited DaysCovered - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleInpatient ConsultationsCovered - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleChemotherapyCovered - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductibleSurgical ServicesSurgeryCovered - 100% after deductibleCovered - 60% after deductibleCovered - 90% after deductibleCovered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductiblePresurgical consultationsCovered - 100%Covered - 60% after deductibleCovered - 100%Covered - 60% after deductibleCovered - 80% after deductibleCovered - 60% after deductible9/9/20207 MEDICAL COVERAGE options .