Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 3810 Emergency & Urgent Care—In Area In Office (Continued) Emergency & Urgent Care—Out of Area/ Out of Network Emergency Room or Urgent Care Center Outpatient Rehabilitative Services Physical, Occupational and Speech Therapy Chiropractic Services Acupuncture Home Health Care Hospice Care Durable Medical Equipment Orthopedics Hearing Aids Audiometric Exam, Evaluation Test, Purchase and Fitting Vision Services Glasses & Contacts Prescription Benefit Plan Benefits Covered at 100% after $150 copay, waived if admitted. Non-emergency use – no coverage. $25 copay for Urgent Care if participating facility. Covered at 100% after $30 copay; short term non chronic conditions; 60 visits per therapy per benefit year, combined with non-net- work benefits. Covered at 100% after $30 copay; up to 36 combined visits per benefit year. Covered at 100% after $30 copay; up to 12 combined visits per benefit year. Covered at 100%; 120 com- bined visits per benefit year. Covered at 100%; 180 day combined lifetime maximum. Covered at 100%. Shoe Orthotics limited to two pair every benefit year, combined with non-net- work benefits. Covered at 80%; limited to $1,200 combined maximum every 3 benefit years. No dollar limit applies to children under the age of 26. Specialist copay for eye refractive exam every benefit year. Discounts on lenses and frames at participating providers. See full description of the CVS/caremark Prescription Benefit on page 11. UnitedHealthcare Choice Plus POS In-Network Covered at the network level. Covered at 70% of Plan Allowance after deductible; 60 visits per therapy per benefit year combined with network benefits. Covered at 70% of Plan Allowance after deductible; up to 36 combined visits per benefit year. Covered at 70% of Plan Allowance after deductible; up to 12 combined visits per benefit year. Covered at 70% of Plan Allowance after deductible; 120 combined visits per benefit year. Covered at 70% of Plan Allowance after deductible; 180 day combined lifetime maximum. Covered at 70% of Plan Allowance after deductible. Shoe Orthotics limited to two pair every benefit year, combined with network benefits. Covered at 70% of Plan Allowance after deductible; limited to $1,200 combined maximum every 3 benefit years. No dollar limit applies to children under the age of 26. Covered at 70% after deductible; one eye exam every benefit year. N/A See full description of the CVS/caremark Prescription Benefit on page 11. UnitedHealthcare Choice Plus POS Out-of-Network Covered at 100% after $150 copay, waived if admitted. Non-emergency use – no coverage. $20 copay for Urgent Care if participating facility. Covered at 100% after $25 copay; Short term non chronic conditions; 60 visits per benefit year. Covered at 100% after $25 copay; up to 36 combined visits per benefit year. Covered at 100% after $25 copay; up to 12 visits per benefit year. Covered at 100%. Covered at 100%. Covered at 100%. Shoe Orthotics limited to two pair every benefit year. Covered at 80%; limited to $1,200 every 3 benefit years. No dollar limit applies to children under the age of 26. Specialist copay for eye re- fractive exam every benefit year. Discounts on lenses and frames at participating providers. See full description of the CVS/caremark Prescription Benefit on page 11. UnitedHealthcare Select EPO In-Network Only $150 copay for emergency room, waived if admitted; $25 for urgent care. $25 copay; limit 30 visits. 90 day limit for speech and occupational therapy. $25 copay; 20 visits per calendar year. $25 copay; 20 visits per calendar year. Covered at 100%. Covered at 100%. Covered at 100% when deemed medically necessary. Covered at 100% per each hearing impaired ear every 36 months for children up to age 26. $25 copay. 25% discount on eyeglasses and 15% initial fitting and purchase discount on contact lenses, when pur- chased from plan providers. See Kaiser Pharmacy description on page 13. Kaiser Permanente HMO In-Network Only 2017 Non-Medicare Medical Summary of Services This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure, the plan brochure will govern. PLEASE NOTE: Copay (copayment) charges are PER VISIT unless specified otherwise. This chart does not apply to Medicare Eligible members. Please see pages 19–23 for Medicare Supplement Plan details.