State of Wisconsin 2013 Benefits Summary Active Employees & Non-Medicare Annuitants

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1 Member Family Policy Annual Deductible None None Policy Co-insurance 10% unless specified below 10% unless specified below Policy Annual Maximum Out of Pocket () $500 $1,000 Policy Lifetime Benefit Maximum Qualified Maximum Dependent Age Clinic Primary Care must be provided within your chosen Health Care Provider Network No Limit Refer to Uniform Benefits Primary Care Office Visits for Adults Preventive Health Examinations for Adults (P) No 0% 100% No Specialist Care Office Visits for Adults 10% Balance of Covered Chiropractic Care for Adults at Clinics Prenatal and Postnatal Maternity Care (P) No 0% 100% No Primary Care Office Visits (Pediatric Care) for children age 17 and under Preventive Health Examinations (Pediatric Care) for No 0% 100% No children age 17 and under (P) Specialist Care Office Visits (Pediatric Care) for children 10% Balance of Covered age 17 and under Chiropractic Care (Pediatric Care) for children age 17 and under at Clinics Preventive Immunizations (P) No* 0% 100% No Diagnostic X-rays and Laboratory Tests Required for 10% Balance of Covered MRI, MRA, PET and CT services only Vision Examinations for children age 5 and under at Optometry (P) No 0% 100% No -Contact lens services provided at an additional fee Vision Examinations for Adults and Children age 6 and over at Optometry -Contact lens services provided at an additional fee Vision Examinations at Optometry Contact lens services provided at an additional fee Specialist Hearing Examinations for Children age 17 10% Balance of Covered and under Specialist Hearing Examinations for Adults 10% Balance of Covered Urgent and Emergency Care Urgent Care Visits Emergency Room Visits -Co-payment waived if admitted as an inpatient directly from the Emergency Room or for observation for 24 hours or longer Emergency Ambulance Service (air/ground) Call your clinic for instructions 10% Balance of Covered No $75 Balance of Covered Group Health Cooperative of South Central Wisconsin () Page 1 of 6 GHC-STATE-3701-DOR *Written is required when services are not provided in a primary care setting by a Contracted Provider. No

2 Call (608) for. Failure to obtain when required will result in the Member receiving a lesser or no Benefit Hospital and Outpatient Inpatient Hospital ; Outpatient Surgical/Non-Surgical /Ambulatory Surgical Care Centers Skilled Nursing Facility -Limited to 120 skilled days per Calendar Year Specified Oral Surgical Procedures -Must be provided at the Center for Oral and Maxillofacial Surgery Prescription Drugs, Supplies and Equipment Outpatient Prescription Drugs; Diabetic Disposable Supplies and Glucose Meters Durable Medical Equipment (DME), Disposable Supplies and Durable Diabetic Equipment Hearing Aids and Cochlear Implants for children under age 18 Limited to one hearing aid per ear every 3 years. Hearing Aids for Participants age 18 and over One hearing aid per ear no more than once every three years up to $1000 plan paid Cochlear Implants for Participants age 18 and over - for Device, Surgery for Implantation of Device and Follow-up Sessions Dental Extraction of Natural Teeth and/or Replacement with Artificial Teeth Because of Accidental Injury Non-Surgical Treatment of Temporomandibular Joint (TMJ)-Diagnostic procedures and non-surgical treatment Limited to a maximum payment by of $1,250 per Participant per Calendar Year. 10% Balance of Covered 10% Balance of Covered N/A Administered by Navitus Health Solutions. Contact Navitus at (866) or visit 20% Balance of Covered 10% Balance of Covered 20% Balance of Covered 20% Balance of Covered Treatment must commence within 18 months of accident. 10% Balance of Covered N/A No No Surgical Treatment of TMJ 10% Balance of Covered *Written is required when services are not provided in a primary care setting by a Contracted Provider. Call (608) for. Failure to obtain when required will result in the Member receiving a lesser or no Benefit. Group Health Cooperative of South Central Wisconsin () Page 2 of 6 GHC-STATE-3701-DOR

3 Mental Health and Substance Use Disorder Mental Health at Clinics-Outpatient No* 10% Balance of Covered Mental Health Inpatient 10% Balance of Covered Mental Transitional 10% Balance of Covered Substance Use Disorder at Gateway Recovery No* 10% Balance of Covered Outpatient Substance Use Disorder Inpatient 10% Balance of Covered Substance Use Disorder Transitional 10% Balance of Covered Additional Eye Exams for illness/injury at Optometry End of Life/Hospice -Coverage available when a Participant s life expectancy is 6 months or less, including Palliative Care Consultation 10% Balance of Covered Health Education Counseling at Clinics (P) No 0% 100% No Home Health -Limited to 50 visits per Participant per Calendar Year -An additional 50 visits may be authorized 10% Balance of Covered Organ Transplants -Limited to transplants listed in Uniform Benefits Outpatient Speech/Occupational/Physical Therapy -Limited to 50 combined visits per Participant per Calendar Year - An additional 50 visits may be authorized 10% Balance of Covered 10% Balance of Covered Autism Spectrum Disorder Autism Spectrum Disorder Diagnostic Testing 10% Balance of Covered Intensive-Level and Non-Intensive Specialist Office Visit 10% Balance of Covered Evidence Based Therapies 10% Balance of Covered *Written is required when services are not provided in a primary care setting by a Contracted Provider. Call (608) for. Failure to obtain when required will result in the Participant receiving a lesser or no Benefit. See your participant materials for more information about s, and Urgent and Emergency instructions. Group Health Cooperative of South Central Wisconsin () Page 3 of 6 GHC-STATE-3701-DOR

4 (P) Preventive Health : when provided in a primary care setting by a Contracted Provider. To include preventive health procedures as deemed appropriate by the United States Preventive Task Force (USPSTF) or an In-Plan Provider meeting specific medical criteria with respect to the age, sex and health status of the Member. and/or testing for ongoing diagnosis and treatment of a condition are not preventive services. not covered, or beyond Benefit maximums, are the participant s responsibility and will not apply to any Policy applicable limits. Co-insurance and amounts are calculated on a Calendar Year basis. Co-payments do not apply to the Policy limits. Group Health Cooperative of South Central Wisconsin () Page 4 of 6 GHC-STATE-3701-DOR

5 2013 Dental Plan Summary State of Wisconsin and Local Government (WPEG) Group Health Cooperative of South Central Wisconsin () Annual Deductible: None Annual Benefit Maximum: None Lifetime Benefit Maximum: None, except Orthodontic Diagnostic and Preventive Examinations X-rays Cleaning treatments twice per calendar year Fluoride treatments twice per calendar year through age 15 Topical applications of sealants through age 18 Space maintenance for primary teeth (the first set of teeth) Restorative Composite fillings for anterior teeth Amalgam fillings for posterior teeth Composite fillings for posterior teeth* Stainless steel crowns for primary teeth (the first set of teeth) Simple and surgical extractions *NOTE: Composite fillings for posterior teeth will be covered at the amalgam filling cost with patient responsibility for the difference. Participant will need to pay this difference on the day of service. Orthodontic Dependent children through age 18 Anesthesia Local anesthesia and analgesia for services related to covered procedures Plan Pays 50% of the first $3,500 in billed charges (maximum payment by of $1,750 per Participant per Lifetime) 100% 0% 50% of the first $3,500 in billed charges; 100% thereafter 100% 0% Emergency Dental Examinations at 100% 0% Dental Health Associates during business hours Note: Restorative dental services performed strictly for cosmetic purposes are excluded. Refer to State and WPEG Dental Plan Exclusions and Limitations on the back of this sheet for a complete listing of services that are excluded from coverage. Where can I Receive Dental under the State of Wisconsin and WPEG Dental Plan? All dental services MUST be obtained from Dental Health Associates in Madison. For an appointment, call: Dental Health Associates of Madison, Ltd. West Dental Health Associates of Madison, Ltd. - East 7017 Old Sauk Road, Madison 49 North Walbridge Avenue, Madison (608) (608) Dental Health Associates of Madison, Ltd. West Dental Health Associates of Madison, Ltd. South 7001 Old Sauk Road, Madison 2971 Chapel Valley Road, Madison (608) (608) (over, please) CSC (09/12)F

6 2013 Dental Plan Summary State of Wisconsin and Local Government (WPEG) What is the State and WPEG Dental Plan? The State and WPEG Dental Plans are a comprehensive dental benefit offered to State of Wisconsin and WPEG employees and their eligible dependents. The coverage is included as part of your health care plan at no additional cost. Who is Covered under the State and WPEG Dental Plan? All State of Wisconsin employees, Graduate Assistants, Annuitants and WPEG employees, and their eligible dependents enrolled in the health care plans. What is Covered under the State and WPEG Dental Plan? Please refer to the back of this page to see an outline of services covered under State and WPEG Dental Plan. Where can I Receive Dental under the State and WPEG Dental Plan? All dental services MUST be obtained from Dental Health Associates in Madison. For an appointment, call Dental Health Associates at: 49 North Walbridge Ave., (608) Old Sauk Road, (608) Chapel Valley Road, (608) Old Sauk Road, (608) Tell the receptionist you have coverage through the State and WPEG Dental Plan. When you arrive, present your ID card. This is the same card used to obtain medical services. Who do I contact with questions regarding the State and WPEG Dental Plan? Please direct any questions about the State and WPEG Dental Plan to the Member Department at (608) or (800) Group Health Cooperative of South Central Wisconsin () State and WPEG Dental Plan Exclusions & Limitations Prosthodontics (i.e. bridges, crowns, caps, dentures) Endodontics (i.e. root canals) Periodontics Deep scale cleaning from dentists not affiliated with State Dental Plan Emergency out-of-area treatment in excess of $150 Cosmetic procedures with respect to any disturbance of TMJ Gold foil restorations Experimental or investigational procedures Oral surgical procedures covered under another plan Drugs or administration of drugs Hospital or physician services covered under Workers Compensation or Employer s Liability Laws Treatment provided before coverage was in effect or after coverage is terminated furnished without charge, procedures, or amounts not specifically identified as covered NOTE: This is only a summary of benefits, exclusions and limitations and is subject to the terms and conditions of the contract. Specified oral surgery procedures are available under the medical plan. does not discriminate on the basis of disability in the provision of programs, services or activities. If you need this printed material interpreted or in an alternative format, or need assistance in using any of our services, please contact Member at (608) ; TDD (608) (over, please) CSC (09/12)F