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 deductible, 50% up to 30 days if preauthorized. For Substance Abuse, limited to 1 treatment program up to $3,000 Outpatient $18 copay After deductible, 50% up to 15 visits 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) None Retail Network No deductible, $8 copay for generic/ 25% brand name ($8 minimum for brand) No deductible, 50%

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.