-d 3UUU~f PPO Plan Summary aDO~ Group # G000487A Kerr County Plan A Plan Effective Date: January 1, 2007 In-Network Out-of-Network Calendar Year Deductible • Individual/EmployeeOnly $1,000 $2,000 • Family • $3,000 $6,000 Out-of-Pocket Limit (includes Calendar Year Deductible) • IndividuaUEmployee Only $2,000 • $ 5,000 • Family $6,000 $15,000 NOTE: The plan pays 100% for most covered services afrer the out-of- '. pocket expense is reached. ~', Maximum (while covered under the plan except as noted below) • $1,000,000 • $1,000,000 NOTE: In-Network and Out-of-Network maximums are combined. Health Reimbursement Account Combined In- &Out-of-Network Em to er-funded amount • IndividuaVEmployee Only $ 600 • • Family $1,800 AFN w IIRA 0706 ASO In-Network Out-of-Network Covered Services (The plan pays the % shown after (The plan pays [he % shown afrer any copay and/or the calendar year any copay and/or the calendar deductible) year deductible) Physician Services ~ • Office Visits • $30 copay each visit, then 90 % • 70% - Primary Care Physician $30 copay each visit, then 90% • 70% - Specialist • Allergy Injections • $30 copay each visit, then 90% • 7po/u • Maternity Services -includes prenatal, delivery and postnatal , 90% 70% physician services • Surgical Services - Inpatient 90% • 70% -Outpatient . 90% • 70% • Nonsurgical Services -Inpatient and Outpatient • 90% • 70% Up to $200 each calendaz year Up to $200 each calendar year • Routine Health Caze (age 18 or older) • 90% • 70% - Primary Caze Physician - Specialist • 90% • 70% • Routine Mammogram (age 35 and over) • 100%, deductible waived • 70% • Preventive Health Caze (through age 17) Up to $200 each calendaz yeaz Up to $200 each calendar year - Primary Care Physician • 100%, deductible waived 70% - Specialist • 100%, deductible waived • 70% • Childhood Immunization (through age 6) • 100%, deductible waived • 70% Hospital Services • Room & Board and Services & Supplies • 90%afrer calendar year • 70%, after the cal yeaz ded deductible Emergency Care Hospital Emergency Room Facility (each visit copay waived if • $50 copay each visit, then • $50 copay each visit, then admitted to the hospital)] 90%afrer the calendar year 70%afrer the cal yeaz ded deductible • Urgent Care Center • 90% • 70% • Ambulance Services • 80%, deductible waived • 80% AFN w HRA 0706 ASO In-Network Out-of-Network COVered Serv1ceS (The plan pays the % shown after (The plan pays the % shown after any copay and/or the calendar year any copay and/or the calendar deductible) yeaz deductible) Mental and Nervous Disorders • Outpatient Visit • 50% up to a maximum • 50%, up to a maximum allowable amount of $70 each allowable amount of $70 visit each visit Inpatient Stay (up to 30 days each calendar yeaz, 60 days plan maximum) • 90% 70% Alcohol & Drug Abuse and/or Substance Abuse Up to $ 10,000 each calendaz year and $30,000 plan maximum • Outpatient Visit (up to 50 visits each calendaz year) 90% 70% Inpatient Stay (up to 30 days each calendaz year, 60 days plan • 90% • 70% maximum) Other Covered Services NOTE: In-Network and Out-of-Network maximums and ]imitations aze combined. • High End Radiology (MRIs, PET Scans, CT Scans, etc) • 90% • 70% • Independent Radiology and Pathology Center • 90% • 70% • Outpatient Facility 90% 70% • Outpatient Therapy Services • 90% • 70% - Physical/Occupational up to 60 visits each calendar yeaz - Speech up to 30 visits each calendar year • Spinal Treatment (up to 30 visits each calendar year) • 90% • 70% • Skilled Nursing Facility (up to 100 days each calendaz year) • 90% • 70%, up to a maximum allowable amount of $200 per day Home Health Caze (up to 100 visits each calendar year) 90% • 70%, up to a maximum allowable amount of $55 per visit • Hospice Care (up to 185 days/visits plan maximum) • 70%, up to a maximum - Inpatient • 90% allowable amount of $55 per day • 90% - Ou anent ~ • 70%, up to a maximum allowable amount of $55 per visit • Durable Medical Equipment 90% 70%, up to a $5,000 plan maximum • Prosthetics 90% 70%, up to a $5,000 plan maximum • Specialty Drugs and Medicines (other then those purchased • 90% • 70% throu h a S ecial Phartna rovider AFN w HRA 0706 ASO Prescription Drug Benefits In-Network The Plan pays 100% after: Out-of-Network The Plan pays: A voluntary generic substitution program applies to this Plan. Retail (up to a 30-day supply) Generic Drugs $10 copay Brand Name Drugs on Formulary $20 copay o 50/° coinsurance Brand Name Drugs not on Formulary $35 copay 50/° coinsurance 50 /o coinsurance Mail Order (up to a 90-day supply) • Generic Drugs • Brand Name Drugs on Formulary $20 copay $40 wpay Mai] Order is not available for • Brand Name Drugs not on Formulary $70 copay non-participating providers Diabetic Supplies For each Diabetic Supply For each Diabetic Supply • Formulary -Retail • $5 copay • 50% coinsurance • Formulary -Mail Order • $10 copay • No benefit • Not on Formulary -Retail • $70 copay • 50% coinsurance • Not on Formulary -Mail Order • $70 copay • No benefit '~ Specialty Pharmacy Providers Specialty Drugs and Medications purchased through a Specialty Pharmacy provider aze payable under the Prescription Drug Retail benefits. See Plan Document for details on how benefits applied. Contracepfives, which require a physician's written prescription are included. Diabetic Supplies include needles, syringes, test tablets, sticks, tapes, strips, lancets and alcohol swabs. AFN w HRA 0706 ASO PP4 P an_Summary Mutual of Omaha wants to help you and your family get the highest quality health care possible. This PPO plan, administrative services provided by United of Omaha Life Insurance Company, is designed [o provide you well-coordinated medical services, at a reasonable price, through a network of carefully selected providers. To get the most out of this plan, please remember the following: • You will receive the higher level of benefits, the in-network benefits, if you seek care from a provider participating in the PPO network. • There are no claim forms [o tiff out when you use in-network providers. • Certain Covered Services are subject to a Maximum Allowable Amount. Maximum Allowable Amount means the charge considered for Covered Services before the applicable Deductible and Coinsurance are applied. In cases where the Usual and Customary Charge is less than the Maximum Allowable Amount, the Usual and Customary Charge would apply. • You (or your physician) must initiate precertification for the covered services shown in the Precertificatlon Review secfion for full benefits to be considered. If precer[ification is not obtained, benefits will be reduced by $500.00. For emergency admissions, contact the Plan within 2 days of treatment. You will receive an ID card showing a phone number to use for initiating precertificadon. • This plan has a voluntary generic program. This means that you and your physician may choose brand name drugs that have generic equivalents without penalty. • A formulary is a list of preferred medications that have been clinically reviewed by the Plan. To find if a medication is on the formulary, caB Express Scripts, Inc. at 800-889-0375. • A prescription drug claim form may be used for claim reimbursement until you receive your prescription drug identificafion card. These forms can also be used ifout-of-network benefits apply to your plan. • If you have auy questions about your benefits, call the Customer Service phone number on your ID card Please note... This Plan Summary provides a brief description of some of the features and benefits of your group health plan. This Summary is no[ a contract. United of Omaha Life Insurance Company complies with Federal mandates as dictated bylaw. The benefits document you will receive will give you a full explanation of your plan's benefits, limitations and exclusions. PLEASE READ YOUR BENEFTTS DOCUMENT CAREFULLY. AFN w H1LA 0706 ASO PPO Plan General Exclusions and Limitations NOTE: Services and supplies which may be Medically Necessary aze not covered by the Plan if they aze specifically excluded or limited in this General Exclusions and Limitations provision. We do no[ pay benefits under the Plan for any Expense or loss unless otherwise specifically provided in the Plan: (a) for an Injury or Sickness: (1) which arises out of, or in the course of, any employment with any employer subject to any workers' compensation law; and (2) for which the Covered Person: a. is entitled to benefits under any workers' compensation or occupational disease law, employer's liability or similar laws, regazdless of whether the employer is incompliance with that law; b. was not compensated under any such laws as a result of the Covered Person's failure to comply with requirements relating to notice of injury, timely filings of claims, and medical treatment authorization; or c. receives any settlement from a workers' compensation carrier, (b) which is in excess of the Usual and Customary Chazge, the Facility Chazge Allowance or the Allowable Chazge; (c) for services or supplies that aze not Medically Necessary; (d) any treatment, service or supply unless it is shown under Covered Services of the Major Medical Benefits; (e) for outpatient prescription drugs and medicines requiring a physician's written prescription and obtained through retail or mail- order pharmacies, including specialty drugs and medicines received at a specialty pharmacy; (f) incurred after insurance ends; (g) which is not the result of an Injury or Sickness; (h) for an Injury or Sickness that occurred while committing a felony or participating in a riot; (i) incurred by a Covered Person while incazcera[ed in a jail, penitentiary, correctional facility or Hospital while incazcerated; (j) which the Covered Person does not have to pay; (k) for Custodial Caze, except as part of a Home Health Caze Plan approved by Us; (1) for Developmental Caze; (m) which results from Reconstructive Surgery, except: (1) foranInjury; (2) for repair of defects which result from surgery; or (3) for the reconstructive (not cosmetic) repair of a congenital defect which materially corrects a bodily malfunction; (n) which results from Cosmetic Surgery or Service; (o) which relates to appetite control, food addictions, eating disorders (except for documented cases of bulimia or anorexia that meet standazd diagnostic criteria, and present significant symptomatic medical problems) or any treatment of obesity (including surgery to treat morbid obesity), unless otherwise specifically provided in the Plan; (p) for routine foot Caze, orthopedic shoes, foot orthotics or other supportive devices for the feet; (q) in connection with dental work, or dental surgery (unless otherwise specifically provided in the Plan), including: (1) treatment or replacement of any tooth or tooth structure, alveolar process, abscess or disease of the periodontal or gingival tissue; or (2) surgery or splinting to adjust dental occlusion; (r) for the treatment of Jaw Joint Disorders (unless otherwise specifically provided in the Plan); (s) related to sexual and gender identity disorders, including but not limited to: (1) sexual dysfunctions; (2) pazaphilias; or (3) gender transformations; (t) for services or supplies for the treatment of impotence or erectile dysfunction; AFN w HRA 0706 ASO (u) for the diagnosis or treatment of the inability to conceive or become pregnant, or the promotion of fertility, including, but not limited to: (1) fertility tests and procedures; (2) reversal of surgical sterilization; or (3) any similar method or treatment which attempts to cause conception or pregnancy by hormone therapy, artificial insemination, in vitro fertilization and/or embryo transfer, unless otherwise specifically provided in the Plan; (v) elective sterilization (w) for chelation therapy, except for acute arsenic, gold, mercury or lead poisoning; (x) for services or supplies which aze not provided in accordance with generally accepted professional standazds and/or medical practice; (y) for services or supplies which: (1) aze considered an Experimental or Investigational Drug or Treatment; or (2) result from or relate to the application of such Experimental or Investigational Drug or Treatment; (z) for services or supplies which are primarily for the Covered Person's education, training or development of skills needed to cope with an Injury or Sickness; (aa) related to smoking cessation or treatment for nicotine addiction, unless otherwise specifically provided in the Plan; (bb) for Acupuncture Treatment (except when used in lieu of an anesthetic agent for covered surgery); (cc) which is primarily for the Covered Person's convenience or comfort or that of the Covered Person's family, cazegiver, companion, sitter, Physician or other person; (dd) for bills for telephone calls, mailings, faxes, e-mails, online evaluations or any other communications to or from a Physician, Hospital or other medical provider, except as required by state or federal law; (ee) which results from breast augmentation or reduction, whether or not Medically Necessary, except for breast reconstruction following a mastectomy as required under state or federal law/regulation; (ff) which results from: (1) pervasive developmental disorders; (2) mental retardation; (3) developmental disorders; (gg) for educational testing or educational remediation; (hh) for therapies designed [o promote personal growth or enhancement absent a diagnosis of a Mental and Nervous Disorder/Alcohol and Drug Abuse and/or Substance Abuse; (ii) for exercise equipment; (jj) for routine eye refractions, unless otherwise specifically provided in the Plan; (kk) for the fitting or cost of visual aids, eyeglasses, vision therapy, radial kemtotomy or similaz surgery done for the correction of any refraction error or astigmatism, except for corneal graft; (Il) for the fitting or cost of heazing aids and related supplies; (mm) for services provided by a person who lives with You in Your home or is a member of Your family (Your spouse; or a child, brother, sister or pazent of you or Your spouse); (nn) for non-surgical Spinal Treatment, except as specifically provided in the Plan; (oo) for Alcohol and Drug Abuse and/or Substance Abuse, except as provided in the Plan; (pp) for Mental and Nervous Disorders, except as specifically provided in the Plan; (qq) for body organ(s)/tissue transplants, except as specifically provided in the Plan; (n) for services or supplies which aze provided or paid for by the federal government or its agencies, except for: (I) the Veterans Administration, when services aze provided to a veteran for a disability which is not service-connected; (2) a military Hospital or facility, when services aze provided to a retiree (or dependent of a retiree) from the armed services; (3) a group health plan established by a government or its agencies for its own civilian employees and their dependents; or (4) Medicaid, if required by a Medicaid assignment of benefits; (ss) which results from an act of declazed or undeclazed waz or armed aggression; or (tt) which: AFN w HRA 0706 ASO (1) is incurred while the Covered Person is on active duty or training in the Atmed Forces, National Guard or Reserves of any state or country; and (2) for which any governmental body or its agencies are liable; Hospital Definifion Hospital means any of the following facilities that aze licensed by the proper authority in the jurisdiction in which they aze located: (a) a facility which: (1) provides inpatient services for the caze and treatment of patients; (2) has a registered graduate nurse (RN) always on duty; (3) has a laboratory and x-ray facility; (4) as a regulaz practice, charges patients for its services; and (5) has a resident Physician on duty or call at all times; (b) a facility which is accredited by the Joint Commission on the Accreditation of Healthcaze Organizations, American Osteopathic Association or the Commission on the Accreditation of Rehabilitative Facilities, if the function of such facility is primarily to provide rehabilitation specifically for treatment of a physical disability. Rehabilitative facilities need not have major surgical facilities; or (c) a facility or a birthing center which is equipped and operated solely to provide prenatal caze; to perform uncomplicated, spontaneous deliveries; and to provide immediate post-parmm caze. Such facility must either be licensed by the state as indicated above or must satisfy all of the following: (1) be directed by at least one (1) Physician specializing in obstetrics or gynecology; (2) have a Physician or nurse midwife present during each birth; (3) provide skilled nursing services in the delivery and recovery rooms (under the direction of an RN or nurse midwife); (4) have at least two (2) birthing rooms or beds, diagnostic x-ray and lab equipment (or a contract to use that of an azea medical facility), and emergency equipment; (5) admit only patients with low-risk pregnancies (and contract with an azea Hospital for transfer of emergency cases); and (6) regulazly chazge patients for services and supplies. When treatment is needed for Mental and Nervous Disorders/ Alcohol and Drug Abuse and/or Substance Abuse, hospital can also mean a facility which is licensed by the proper authority of the jurisdiction in which it is located and: (a) provides inpatient services for the Gaze and treatment of patients; (b) is equipped to treat Mental and Nervous Disorders/ Alcohol and Drug Abuse and/or Substance Abuse; (c) has a resident Physician on duty or on call at all times; (d) has a registered nurse (RN) always on duty; and as a regulaz practice, charges patients for its services. A hospital does not include a facility or institution, or units within a facility or institution, which is licensed or used principally as a clinic, convalescent home, rest home, nursing home, home for the aged, halfway house, boazd and caze facility, residential treatment center, `wilderness" program, treatment group home or "boot camp". Medical Emergency means a medical condition or behavioral condition of sudden onset that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the Covered Person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopazdy; (b) serious impairment to bodily functions; (c) serious disfigurement of the Covered Person; serious impairment of any bodily organ or part of the Covered Person; or in [he case of a behavioral condition, placing the health of the Covered Person or other person hr serious jeopazdy. PLEASE READ YOUR BENEFITS DOCUMENT CAREFULLY AFN w HRA 0706 ASO NOTIFICATION Women's Health and Cancer Rights Act of 1998 On October 21, 1998, the federal government passed the Women's Health and Cancer Rights Act of 1998. One of the provisions of this act requires group health plans to notify health plan members of their rights under this law. What benefits does the law guarantee? Under this law, group health plans that provide medical and surgical benefits in connection with a mastectomy must provide benefits for certain reconstructive surgery. This includes: • Reconstruction of the breast on which a mastectomy has been performed • Surgery and reconstruction of the other breast to produce a symmetrical appeazance • Prostheses and physical complications of all stages of mastectomy, including lymphedemas The law also states that "the services will be considered in a manner determined in consultation with the attending physician and the patient." In other words, you and your physician will determine the most appropriate treatment for your individual situation. Coverage of these services is subject to the terms and conditions of your health plan, including your plan's normal copayment, annual deductibles and coinsurance provisions. For more information If you have any questions regazding your benefits or rights under this Act, call the Mutual of Omaha customer service number on your health plan ID cazd, or contact your plan administrator. AFN w HRA 0706 ASO