Excellus BluePPO Signature Hybrid 5

Excellus BluePPO Signature Hybrid 5 Drug Coverage Excluded Benefit Time Period: 01/01/2017-12/31/2017 Trinity Health - Syracuse Essential General Cost Sharing Expenses - Single Domestic - $1,000 $2,500 $4,000 - Family Domestic - $2,000 $5,000 $8,000 30% 40% Annual Out of Pocket Maximum - Single Domestic - $3,500 $5,500 $9,000 Annual Out of Pocket Maximum - Family Domestic - $7,000 $11,000 $18,000 Each family member is only subject to the single Annual Out of Pocket Maximum any combination of family members can satisfy the family Annual Out of Pocket Maximum Individual Each family member is only subject to the single Annual Out of Pocket Maximum any combination of family members can satisfy the family Annual Out of Pocket Maximum Individual Office Visit Cost Shares Cost Share - Primary Care Cost Share - Specialist 30% 30% 40% 40% Plan Limits Plan/Calendar Year Diabetic Preauthorization and Step Therapy Plan Year Benefits Yes Who is Domestic Partner Coverage 1 of 8 946724-1 10/20/2016 11:08:01

Inpatient s Inpatient Facility Inpatient Hospital s Mental Health Care Substance Use Detoxification Skilled Nursing Facility Physical Rehabilitation Maternity Care $750 Copayment then 30% 20% 20% $750 Copayment then 30% $750 Copayment then 30% $750 Copayment then 30% 40% 40% 40% 40% 40% 40% 120 Days per contract year Limits are combined Domestic and INN and OON. 60 Days per year Limits are combined Domestic INN and OON. Inpatient Professional s Inpatient Hospital Surgery Anesthesia 20% 20% 30% 30% 40% 40% Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Outpatient Facility s Outpatient Facility s SurgiCenters and Freestanding Ambulatory Centers Surgical Care Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Domestic - Inclusive of Primary 30% 30% 30% 30% 30% 40% 40% 40% 40% 40% OP Surgery Co-pay $50 Domestic, $100 INN, $200 OON Is inclusive in the Home Care benefit and not covered as a separate benefit. 2 of 8 946724-1 10/20/2016 11:08:01

Dialysis Mental Health Care Substance Use Care 30% 20% 20% 40% 40% 40% Includes Partial Hospitalization Includes Partial Hospitalization Home and Hospice Care Home Care Home Care 30% 40% 120 days per year Limits are combined Domestic INN and OON. Hospice Care Hospice Care Inpatient Domestic - 0% 0% 40% Outpatient and Office Professional s Professional s Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis 20% 20% 20% 20% 20% 20% 30% 30% 30% 30% 30% 30% 40% 40% 40% 40% 40% 40% Is inclusive in the Home Care benefit and not covered as a separate benefit. 3 of 8 946724-1 10/20/2016 11:08:01

Mental Health Care Maternity Care TeleMedicine Program Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine 20% 20% Not 20% 20% 20% 20% 30% Not 30% 30% 30% 40% 40% Not 40% 40% 40% 40% Not 20 visits per year Allergy Testing includes injections and scratch and prick tests. Includes desensitization treatments (injections & serums). Limits are combined Domestic, INN and OON. Rehab and Habilitation Outpatient Facility Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 30% 30% 30% 40% 40% 40% occupational therapy. occupational therapy. 45 Visits per contract year occupational therapy. Not for learning disabilities and congenital defects unless following surgery. 4 of 8 946724-1 10/20/2016 11:08:01

Outpatient Professional s Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 20% 20% 20% 30% 30% 30% 40% 40% 40% occupational therapy. occupational therapy. occupational therapy. Not for learning disabilities and congenital defects unless following surgery. Preventive s Preventive Professional s Meeting Federal Guidelines* Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Pre/Post-Natal Care Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional 40% 40% 40% 40% 40% 40% 40% 40% 1 Exam per year Xrays, EKG and lab procedures performed as part of the health maintenance exam 100% DOM and Innet First base Mammogram between ages 35 and over CIF. First Diagnostic Colonoscopy will be covered in full regardless of age. Preventive Facility s Meeting Federal Guidelines* Cervical Cytology Preventative Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility 40% 40% 40% 40% First base Mammogram between ages 35 and over CIF. First Diagnostic Colonoscopy will be covered in full regardless of age. 5 of 8 946724-1 10/20/2016 11:08:01

Preventive services in addition to those required under Federal Guidelines - Professional Prostate Cancer Screening Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional 20% 30% 40% 40% 40% 40% First base Mammogram between ages 35 and over CIF. First Diagnostic Colonoscopy will be covered in full regardless of age. Preventive services in addition to those required under Federal Guidelines - Facility Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility 30% 40% 40% 40% First base Mammogram between ages 35 and over CIF. First Diagnostic Colonoscopy will be covered in full regardless of age. Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies Acupuncture Private Duty Nursing 20% 20% 20% 20% Not 20% 30% 30% 20% 30% Not 30% 40% 40% 40% 40% Not 40% No coverage for Insulin and supplies through a pharmacy- covered through Carve-out Rx Vendor - CVS/Caremark 120 visits per year Private Duty Nursing not covered in an inpatient hospital or any other health care facility 6 of 8 946724-1 10/20/2016 11:08:01

Emergency s ER Facility Facility Emergency Room Visit Domestic - $100 Copayment $100 Copayment $100 Copayment Non emergency use of ER DOM-$100 copay then 20% subject to deductible Innet-$100 copay then 30% subject to deductible OON-$100 copay then 40% subject to deductible Transportation Prehospital Emergency and Transportation - Ground or Water 20% 20% DOM $1,000 deduct then 20% coinsurance. Innet $2,500 deduct then 20% coinsurance. OON $4,000 deduct then 20% coinsurance Urgent Care Urgent Care Center Facility Visit 20% 20% DOM $1,000 deduct then 20% coinsurance. Innet $2,500 deduct then 20% coinsurance. OON $4,000 deduct then 20% coinsurance Ancillary Benefits Vision Adult Eye Exams - Routine Domestic - Not Not Not Not Adult Eyewear - Routine Domestic - Not Not Not Not Pediatric Eye Exams - Routine Domestic - Not Not Not Not Pediatric Eyewear - Routine Domestic - Not Not Not Not Rx Benefits Rx Plan Rx Plan Drug Coverage Excluded 7 of 8 946724-1 10/20/2016 11:08:01

Rx Benefits Days Supply Per Retail Order Domestic - 30 30 Days Supply Per Mail Order Domestic - 90 90 Copays Per Mail Order Supply Domestic - NA NA This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of the contract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefits. * For non-grandfathered groups, Preventive s coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive s Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 8 of 8 946724-1 10/20/2016 11:08:01