Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO Your Cost If Your Cost If Common You Use a You Use a Medical Event Services You May Need Participating Non- Limitations & Exceptions Provider Participating Provider $10 copay/ Covers up to a 30-day supply (retail If you need drugs to Generic drugs prescription (retail 40% coinsurance prescription); 31-90 day supply (mail treat your illness or and mail order) order prescription) condition 20% coinsurance Preferred brand drugs (retail and mail 40% coinsurance –––––––––––none––––––––––– More information order) about prescription 40% coinsurance drug coverage is Non-preferred brand drugs (retail and mail 60% coinsurance –––––––––––none––––––––––– available at www. order) [insert]. Specialty drugs 50% coinsurance 70% coinsurance –––––––––––none––––––––––– If you have Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance –––––––––––none––––––––––– outpatient surgery Physician/surgeon fees 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If you need Emergency room services 20% coinsurance 20% coinsurance –––––––––––none––––––––––– immediate medical Emergency medical transportation 20% coinsurance 20% coinsurance –––––––––––none––––––––––– attention Urgent care 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If you have a Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance –––––––––––none––––––––––– hospital stay Physician/surgeon fee 20% coinsurance 40% coinsurance –––––––––––none––––––––––– Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 3 of 8 at www.[insert] or call 1-800-[insert] to request a copy.