Benefit Preferred Provider You Pay Non-PPO Provider You Pay Hospital Benefits Inpatient Room and Board 10% if precertified $300 copay and 30% Inpatient-Other Charges 10% 30% Outpatient After deductible, 10% After deductible, 30% Physicians' Benefits Office Visits $18 copay, no deductible After deductible, 30% Other professional fees (hospital visits, etc.) After deductible, 10% After deductible, 30% Other Outpatient Services Lab, x-ray, therapy, covered routine services After deductible, 10% After deductible, 30% Accidental Injury Outpatient service, (Within 24 hours of accident) Nothing, no deductible Only the difference between the Plan allowance and the billed amount Well Child Care Recommended Immunizations Nothing, no deductible Only the difference between the Plan allowance and the billed amount; no deductible Examinations and lab tests Nothing, no deductible Only the difference between the Plan allowance and the billed amount; no deductible Mental Health and Substance Abuse In-Network - You Pay Out-of-Network Payment Rate Inpatient Inpatient services of a hospital, 10% if preauthorized. After $300 per admission, you pay 30% of our allowance. Outpatient $18 copay After $500/$1,000 calendar year deductible, 30% of the Plan allowance Prescription Drugs In-Network-You Pay (Medicare Same as Non-Medicare) Out-of-Network-You Pay (Medicare Same as Non-Medicare) Mail Order No deductible, $15 copay for generic/ 25% brand name ($12 minimum for brand), maximum coinsurance of $600 per prescription. None Retail Network No deductible, $8 copay for generic/ 25% brand name ($8 minimum for brand), maximum coinsurance of $200 per prescription. No deductible, 50% Dental Care Dental services 30% of Plan allowance plus amount over our allowance 30% of Plan allowance plus amount over our allowance Protection against catastrophic costs (out-of-pocket maximum): Flexible benefits option, 24-hour nurse line, Services for deaf and hearing-impaired, Wellness benefit, Disease Management Program, Review and reward program PPO: Nothing after $4,000/Self Only or Family enrollment per year Non-PPO: Nothing after $10,000/Self Only or Family enrollment per year Some costs do not count toward this protection Special Features Flexible benefits option, 24-hour nurse line, Services for deaf and hearing-impaired, Wellness benefit, Disease Management Program, Review and reward program

Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, please read about the specific benefit.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

An asterisk (*) means the item is subject to the calendar year deductible, $275 (PPO) or $500 (Non-PPO). And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician or other health care professional.

This is a summary of features of the APWU Health Plan. Before making a final decision, please read the Health Plan's Federal Brochure (RI 71-004). All benefits are subject to the definitions, limitations and exclusions set forth in the Plan's Brochure.