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COMPREHENSIVE

COVERAGE

PREVENTIVE AND WELLNESS

BENEFITS

LABORATORY BENEFITS

LabOne

PPO SAVINGS

FREEDOM OF CHOICE

MULTIPLE PLAN DESIGNS

COST CONTAINMENT

C O PAY P P O I N S U R A N C E P L A N S

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PPO COPAY 1 90/70 PLAN PPO COPAY 4 90/70 PLAN

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK ANNUAL DEDUCTIBLE

—If you have employee Only coverage:

—Total if you have Spouse, Children or Family coverage: $100$200 $300$600 OUT-OF-POCKET ANNUAL MAXIMUM

(Includes deductible)

—If you have employee Only coverage:

—Total if you have Spouse, Children or Family coverage:

$750 $1,500 $1,500 $3,000 $2,000 $4,000 $4,000 $8,000 COINSURANCE

(Up to out-of-pocket maximum then 100%) 90% 70% 90% 70%

DOCTOR’S ENCOUNTER FEE $10 Deductible then 70% $15 Deductible then 70% PREVENTIVE CARE

Pap smears, prostate cancer screening and mammography screening (Age and frequency limitations apply)

100%—No deductible

ROUTINE PHYSICALS STANDARD - Ages two and older up to $500 maximum—not subject to deductible, paid at 100% OPTIONAL - $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and above—

not subject to deductible, paid at 100%

OUTPATIENT LAB TESTS THROUGH LABONE 100% —No deductible for covered testing processed at LabOne. (Provider collection and handling fees may apply and are subject to health benefit plan provisions)

PRESCRIPTION DRUGS Please refer to separate prescription drug benefit brochure for available options HOSPITALIZATION

Semi-Private

Private Room Limit of Semi-Private room rateDeductible then 90% of Semi-Private room rateDeductible then 70% of Semi-Private room rateDeductible then 90% of Semi-Private room rateDeductible then 70% PHYSICIAN SERVICES

Inpatient Surgery

Outpatient/Ambulatory Surgery Deductible then 90% Deductible then 70% Deductible then 90% Deductible then 70% WELL BABY UP TO AGE 2 Encounter Fee (Copay)

applies Deductible then 70% Encounter Fee (Copay) applies Deductible then 70% MATERNITY

Prenatal care

Delivery and inpatient well baby care

Deductible then 90% Deductible then 70% Deductible then 90% Deductible then 70%

SUPPLEMENTAL ACCIDENT BENEFIT First $500 paid at 100%, then deductible and coinsurance apply

TRANSPLANTS —100% for transplant performed at a designated Center of Excellence facility, no deductible. —$300,000 Lifetime Maximum for transplant services performed at a facility other than a Center of Excellence,

out-of-network deductible and coinsurance apply.

HOSPICE CARE 100%—No deductible

OTHER COVERED MEDICAL EXPENSES Deductible then 90% Deductible then 70% Deductible then 90% Deductible then 70%

PLAN MAXIMUMS

HOME HEALTH CARE Limited to 50 visits per Calendar Year EXTENDED CARE FACILITY Limited to 60 days per Calendar Year

HEARING BENEFITS Hearing examination - up to $25 per 60 consecutive month period. Hearing aid including services and supplies – up to $300 per 60 consecutive month period. Hearing aid repair – all expenses up to $50 per Calendar Year

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PPO COPAY 5 80/60 PLAN PPO COPAY 6 80/60 PLAN

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK ANNUAL DEDUCTIBLE

—If you have employee Only coverage:

—Total if you have Spouse, Children or Family coverage: $1,000$500 $1,000$2,000 OUT-OF-POCKET ANNUAL MAXIMUM

(Includes deductible)

—If you have employee Only coverage:

—Total if you have Spouse, Children or Family coverage:

$3,500 $7,000 $6,500 $13,000 $4,000 $8,000 $7,000 $14,000 COINSURANCE

(Up to out-of-pocket maximum then 100%) 80% 60% 80% 60%

DOCTOR’S ENCOUNTER FEE $20 Deductible then 60% $25 Deductible then 60% PREVENTIVE CARE

Pap smears, prostate cancer screening and mammography screening (Age and frequency limitations apply)

100%—No deductible

ROUTINE PHYSICALS STANDARD - Ages two and older up to $500 maximum—not subject to deductible, paid at 100% OPTIONAL - $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and above—

not subject to deductible, paid at 100%

OUTPATIENT LAB TESTS THROUGH LABONE 100% —No deductible for covered testing processed at LabOne. (Provider collection and handling fees may apply and are subject to health benefit plan provisions)

PRESCRIPTION DRUGS Please refer to separate prescription drug benefit brochure for available options HOSPITALIZATION

Semi-Private

Private Room Limit of Semi-Private room rateDeductible then 80% of Semi-Private room rateDeductible then 60% of Semi-Private room rateDeductible then 80% of Semi-Private room rateDeductible then 60% PHYSICIAN SERVICES

Inpatient Surgery

Outpatient/Ambulatory Surgery Deductible then 80% Deductible then 60% Deductible then 80% Deductible then 60% WELL BABY UP TO AGE 2 Encounter Fee (Copay)

applies Deductible then 60% Encounter Fee (Copay) applies Deductible then 60% MATERNITY

Prenatal care

Delivery and inpatient well baby care

Deductible then 80% Deductible then 60% Deductible then 80% Deductible then 60%

SUPPLEMENTAL ACCIDENT BENEFIT First $500 paid at 100%, then deductible and coinsurance apply

TRANSPLANTS —100% for transplant performed at a designated Center of Excellence facility, no deductible. —$300,000 Lifetime Maximum for transplant services performed at a facility other than a Center of Excellence,

out-of-network deductible and coinsurance apply.

HOSPICE CARE 100%—No deductible

OTHER COVERED MEDICAL EXPENSES Deductible then 80% Deductible then 60% Deductible then 80% Deductible then 60%

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PPO COPAY A 80/60 PLAN PPO COPAY B 80/60 PLAN

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK ANNUAL DEDUCTIBLE

—If you have employee Only coverage:

—Total if you have Spouse, Children or Family coverage:

$1,000 $2,000 $2,000 $4,000 $1,500 $3,000 $3,000 $6,000 OUT-OF-POCKET ANNUAL MAXIMUM

(Includes deductible)

—If you have employee Only coverage:

—Total if you have Spouse, Children or Family coverage: $4,000$8,000 $16,000 $8,000 $4,500$9,000 $18,000 $9,000 COINSURANCE

(Up to out-of-pocket maximum then 100%) 80% 60% 80% 60%

DOCTOR’S ENCOUNTER FEE $25 Deductible then 60% $25 Deductible then 60% PREVENTIVE CARE

Pap smears, prostate cancer screening and mammography screening (Age and frequency limitations apply)

100%—No deductible

ROUTINE PHYSICALS STANDARD - Ages two and older up to $500 maximum—not subject to deductible, paid at 100% OPTIONAL - $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and above—

not subject to deductible, paid at 100%

OUTPATIENT LAB TESTS THROUGH LABONE 100% —No deductible for covered testing processed at LabOne. (Provider collection and handling fees may apply and are subject to health benefit plan provisions)

PRESCRIPTION DRUGS Please refer to separate prescription drug benefit brochure for available options HOSPITALIZATION

Semi-Private Private Room Limit

Deductible then 80% of Semi-Private room rate

Deductible then 60% of Semi-Private room rate

Deductible then 80% of Semi-Private room rate

Deductible then 60% of Semi-Private room rate PHYSICIAN SERVICES

Inpatient Surgery

Outpatient/Ambulatory Surgery Deductible then 80% Deductible then 60% Deductible then 80% Deductible then 60% WELL BABY UP TO AGE 2 Encounter Fee (Copay)

applies

Deductible then 60% Encounter Fee (Copay) applies

Deductible then 60% MATERNITY

Prenatal care

Delivery and inpatient well baby care

Deductible then 80% Deductible then 60% Deductible then 80% Deductible then 60%

SUPPLEMENTAL ACCIDENT BENEFIT First $500 paid at 100%, then deductible and coinsurance apply

TRANSPLANTS —100% for transplant performed at a designated Center of Excellence facility, no deductible. —$300,000 Lifetime Maximum for transplant services performed at a facility other than a Center of Excellence,

out-of-network deductible and coinsurance apply.

HOSPICE CARE 100%—No deductible

OTHER COVERED MEDICAL EXPENSES Deductible then 80% Deductible then 60% Deductible then 80% Deductible then 60%

PLAN MAXIMUMS

HOME HEALTH CARE Limited to 50 visits per Calendar Year EXTENDED CARE FACILITY Limited to 60 days per Calendar Year

HEARING BENEFITS Hearing examination - up to $25 per 60 consecutive month period. Hearing aid including services and supplies – up to $300 per 60 consecutive month period. Hearing aid repair – all expenses up to $50 per Calendar Year

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PPO COPAY C 80/60 PLAN

IN-NETWORK OUT-OF-NETWORK

ANNUAL DEDUCTIBLE

—If you have employee Only coverage:

—Total if you have Spouse, Children or Family coverage: $2,000$4,000 $4,000$8,000 OUT-OF-POCKET ANNUAL MAXIMUM

(Includes deductible)

—If you have employee Only coverage:

—Total if you have Spouse, Children or Family coverage:

$5,000 $10,000

$10,000 $20,000 COINSURANCE

(Up to out-of-pocket maximum then 100%) 80% 60%

DOCTOR’S ENCOUNTER FEE $25 Deductible then 60%

PREVENTIVE CARE

Pap smears, prostate cancer screening and mammography screening (Age and frequency limitations apply)

100%—No deductible

ROUTINE PHYSICALS STANDARD - Ages two and older up to $500 maximum—not subject to deductible, paid at 100% OPTIONAL - $250 every 5 years, age 2-44; $500 every 2 years, age 45-55; or $750 every year, age 56 and

above—not subject to deductible, paid at 100%

OUTPATIENT LAB TESTS THROUGH LABONE 100% —No deductible for covered testing processed at LabOne. (Provider collection and handling fees may apply and are subject to health benefit plan provisions)

PRESCRIPTION DRUGS Please refer to separate prescription drug benefit brochure for available options HOSPITALIZATION

Semi-Private

Private Room Limit of Semi-Private room rateDeductible then 80% of Semi-Private room rateDeductible then 60% PHYSICIAN SERVICES

Inpatient Surgery

Outpatient/Ambulatory Surgery Deductible then 80% Deductible then 60% WELL BABY UP TO AGE 2 Encounter Fee (Copay) applies Deductible then 60% MATERNITY

Prenatal care

Delivery and inpatient well baby care

Deductible then 80% Deductible then 60%

SUPPLEMENTAL ACCIDENT BENEFIT First $500 paid at 100%, then deductible and coinsurance apply

TRANSPLANTS —100% for transplant performed at a designated Center of Excellence facility, no deductible. —$300,000 Lifetime Maximum for transplant services performed at a facility other than a Center of Excellence,

out-of-network deductible and coinsurance apply.

HOSPICE CARE 100%—No deductible

OTHER COVERED MEDICAL EXPENSES Deductible then 80% Deductible then 60%

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PAY LESS FOR MORE

No one can be absolutely certain about the future of

health care in America. However, one thing is clear,

engineering firms and their employees are demanding

greater flexibility and more affordable health

insurance options.

To meet this demand, the ACEC Life/Health Trust

has developed the Copay PPO (Preferred Provider

Organization) Plans—a balance of cost savings and

flexibility along with exceptional access to care.

These plans are an attractive choice for any firm

wishing to offer cost sharing options of deductibles

and coinsurance combined with the convenience

of self-directed referral to an extensive network of

medical professionals.

The Copay PPO Plans cover basic medical expenses,

including wellness, preventive and recovery care.

The plan also helps protect insureds against hospital

and physician costs resulting from catastrophic illness

or injury.

FREEDOM OF CHOICE

Insureds may choose any physician or hospital.

Of course, there is an advantage for insureds to stay

in-network because benefits will be paid at their

highest level.

MULTIPLE PLAN DESIGNS

Participating firms may choose from a range of

Copay PPO Plans. The plans vary by coinsurance,

deductibles and out-of-pocket maximums. Refer to

the Plan Comparison chart on the following pages

for more information. This chart saves you time

by organizing essential information about available

benefits and choices.

FOUR LEVELS OF COVERAGE

Each Copay PPO Plan includes a choice of four levels

of coverage: Employee Only; Employee Plus Spouse;

Employee Plus Child(ren); Employee plus Spouse and

Child(ren).

PROTECT YOUR BOTTOM LINE

Today, medical coverage is one of your most valued

employee benefits. Copay PPO Plans offer various

levels of coverage to help protect engineering firm

employees from serious financial hardship. But

that's not all. The cost containment provisions,

such as Preadmission Hospital Certification, Case

Management, Continued Stay Review, Wellness and

Preventive programs offer employers a solid line

of defense against rising health care costs. These

features are designed to help protect your bottom

line while at the same time providing comprehensive

medical care for insureds.

COMPREHENSIVE COVERAGE

The following coverage is included with the ACEC

Life/Health Trust Copay PPO Plan:

Vision Benefits through Vision Service Plan

Wellness Benefits

Prescription Drug Card

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MEDICAL

EXCLUSIONS/

LIMITATIONS

M E D I C A L E X C L U S I O N S / L I M I T A T I O N S

EXCLUSIONS

Benefits will not be paid for expenses arising from or in connection with: • Charges in excess of the Prevailing Fee.

• Treatment, services or supplies which are: - not Medically Necessary;

- experimental, investigational, educational or primarily for the purpose of medical or other research; - not prescribed by a Physician as necessary to treat a Sickness or Injury;

- received without charge or legal obligation to pay;

- supplies or treatment that would not routinely be paid in the absence of insurance;

- furnished by an employer maintained health department or clinic, by a labor union or other similar person or group; or

- performed or received when coverage provided herein is not in effect.

• War, declared or undeclared, acts of war, or while in the military service of any country.

• Participating in a riot, civil disturbance or illegal occupation; or commission of, or attempt to commit, a felony or crime which would be a felony if prosecuted.

• Loss due to intentionally self-inflicted Sickness or Injury, if the Sickness or Injury is not the result of a medical condition.

• Loss due to suicide, if the suicide is not the result of a medical condition. • Services provided due to a court order.

• Expenses incurred for Prescription Drugs, except if received while an inpatient.

• Service or supply furnished by a member of the Immediate Family or person who usually resides in Your home. • Physician fees for any treatment when the Physician is not physically present or fees for missed appointments. • Dental care or treatment, except as specifically stated in Covered Charges.

• Dental implantology.

• Eye refractions; eyeglasses; contact lenses or the fitting of contact lenses (unless necessary after surgery) or examinations for their prescription or fitting; eye exercises; or services or supplies related to the treatment of refractive error.

• Cosmetic surgery, except as specifically stated in Covered Charges.

• Fertility drugs, contraceptives and rogain (only for plans without Caremark). • Sex transformations or services related to sexual dysfunction.

• Artificial insemination; surrogate pregnancy; in vitro fertilization and embryo transfer; and reversal of vasectomy or tubal ligation.

• Expenses incurred in connection with the pregnancy of a Dependent child, except for Complications of Pregnancy. • Behavior modification or psychological counseling in connection with smoking cessation and weight control, including, but not limited to: vitamins, diet supplements and health club memberships.

• Treatment of exogenous obesity.

• Vitamins; minerals or nutritional substances or supplements.

• Sickness or Injury covered by any Workers' Compensation Act or similar law, except if You are not eligible for Workers' Compensation or similar coverage.

• Hearing aid batteries.

• Services of any educational institution.

LIMITATIONS

Pre-existing Condition Limitation

Expenses that result from care or treatment of a Pre-existing Condition will not be considered as Covered Charges. This limit will not apply to :

• a Covered Person, after the first 12 months following the date he became covered or the first day of the waiting period if earlier; or

Figure

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