2016 Benefit Summary HDHP IHDHP II BenefitsIn-NetworkOut-of-NetworkIn-NetworkOut-of-Network Annual Deductible (Individual/Family)$1,500* / $3,000$3,000* / $9,000$3,200* / $6,400$6.400* / $12,800 * Individual deductible does not apply if your policy covers 2+ people. 2+ people requires full family deductible. Annual Out-Of-Pocket (Individual/Family)$3,000 / $6,000$6,000 / $18,000$6,350 / $12,700$12,700 / $25,400 Coinsurance You pay 20% Plan pays 80% You pay 40% Plan pays 60% You pay 40% Plan pays 60% You pay 60% Plan pays 40% Lifetime MaximumUnlimited Inpatient Hospital ServicesDeductible + 20%Deductible + 40% Deductible + 60% Emergency RoomDeductible + 20% Deductible + 40% Urgent Care FacilityDeductible + 20%Deductible + 40% Deductible + 60% Preventive Services**Covered 100%Deductible + 40%Covered 100%Deductible + 60% Office Visits - PCPDeductible + 20%Deductible + 40% Deductible + 60% Office Visits - SpecialistDeductible + 20%Deductible + 40% Deductible + 60% Surgery Hospital or Ambulatory Center Office Outpatient Deductible + 20% Deductible + 40% Deductible + 60% X-Ray & Lab Tests Preventive Diagnostic 100% for PCP (Preventive Only) Deductible + 20% Ded+40% for PCP (Prev Only) Deductible + 40% 100% for PCP (Preventive Only) Deductible + 40% Ded+60% for PCP (Prev Only) Deductible + 60% Mental Health Care Inpatient Outpatient Care Deductible + 20% Deductible + 40% Deductible + 60% Substance Abuse Care Inpatient Care Outpatient Care Deductible + 20% Deductible + 40% Deductible + 60% Prescription Drugs Retail (31-day supply) Tier 1, 2 and 3Deductible + 20%Deductible + 40% Deductible + 60% Prescription Mail Order (90-day supply) Tier 1, 2 and 3Deductible + 20%Deductible + 40% Deductible + 60% * * Preventive care is not received in response to a diagnosis. Preventive care includes routine physicals and office visits, well baby and well child care, annual well woman examinations, immunizations, and screenings such as colonoscopies, mammograms and pap smears. Contact United Healthcare for more information.

2016 Benefit Summary EPO (IN-NETWORK COVERAGE ONLY) BenefitsIn-Network ONLY Annual Deductible (Individual/Family)None Annual Out-Of-Pocket (Individual/Family)$1.500 / $3,000 CoinsuranceNot Applicable Lifetime MaximumUnlimited Inpatient Hospital Services$250 Copay Emergency Room$150 Copay (Waived if Admitted) Urgent Care Facility$50 Copay Preventive Services*Covered 100% Office Visits - PCP$15 Copay Office Visits - Specialist$30 Copay Surgery Hospital or Ambulatory Center Office Outpatient $100 Copay X-Ray & Lab Tests Preventive Diagnostic 100% for PCP (Preventive Only) Covered 100% Mental Health Care Inpatient Outpatient Care $250 Copay $15 Copay Substance Abuse Care Inpatient Care Outpatient Care $250 Copay $15 Copay Prescription Drugs Retail (31-day supply) Tier 1 Tier 2 Tier 3 $10 Copay $30 Copay $50 Copay Prescription Mail Order (90-day supply) Tier 1 Tier 2 Tier 3 $25 Copay $75 Copay $125 Copay

DENTAL BenefitsIn-NetworkOut-of Network (1) *Out-of-Network (2) * Annual Deductible (Individual/Family)$50 / $150$100 / $300 Preventive Care Cleaning Oral Exam Sealant (per tooth) X-rays Fluoride Treatment (under age 14) Covered 100% Basic Care Anesthesia Fillings (one surface) Periodontal Surgery and Maintenance Repair Crowns, Bridges and Dentures Root Canal Scaling and Root Planning Simple Extractions Surgical Extractions Deductible + 20% Deductible + 50% Major Care Bridges Dentures Dental Implants Inlays Onlays Veneers (injury only) Single Crowns Deductible + 50% Deductible + 75% OrthodontiaNot Covered Annual Benefit Maximum$1,500 per person * The out-of-network benefits are based on what state you reside in and are based on state regulations. 1. Out-of-network for those that reside in the following states; CA, AZ, WA, VA, MO and TX. 2. Out-of-network for those that reside in the following states; NC, SC and CO. VISION BenefitsIn-NetworkOut-of-Network Exam (1 every 12 months)$20 CopayUp to $40 Lenses (1 every 12 months)$20 CopayUp to $80 Frames (1 every 24 months)Up to $130 Retail AllowanceUp to $45 Contacts (1 every 12 months) Elective Medically Necessary Up to $150 Covered 100% Up to $150 Up to $210