MEDICAL BENEFITS

Blue Preferred PPO Plan Highlights

• Utilizes the national BlueCard PPO network • Traditional PPO with lower deductible • To locate an in-network doctor visit www.member.carefirst.com • For out-of-network coverage, the allowed benefit is what CareFirst would have paid an in-network provider in the same area for the service. Your out-of-network provider can bill you the difference between what CareFirst pays and their actual charges.

Deductible Out-of-Pocket Maximum - Medical & Rx Preventive Services

Well-Child Care (Exams & Immunizations) Adult Physical Exam (including routine GYN) Cancer Screenings (at set ages) & Pap Tests

Physicians Office Visit - PCP or Specialist

Physical, Speech & Occupational Therapy Chiropractic

Diagnostic, Lab and X-ray Imaging: CT, PET scan, MRIs Urgent Care Facility Hospital Emergency Room Hospital Facility Services Outpatient Facility Services Prescription Coverage

Tier I – Generic Tier II - Preferred Brand Tier III - Non-Preferred Brand Tier IV - Specialty Preferred Brand Tier V- Specialty Non-Preferred Brand 90-Day Maintenance

CareFirst PPO

Amounts shown are what the member will pay In-Network Out-of-Network

$300 Ind | $600 Fam $1,500 Ind | $3,000 Fam $600 Ind | $1,200 Fam $3,000 Ind | $6,000 Fam

No Charge No Charge No Charge $20 Copay $20 Copay $20 Copay

20% of Allowed Benefit Deductible then 20% of Allowed Benefit 0% of Allowed Benefit Deductible then 20% of Allowed Benefit Deductible then 20% of Allowed Benefit Deductible then 20% of Allowed Benefit Deductible then No Charge Deductible then 20% of Allowed Benefit Deductible then No Charge Deductible then 20% of Allowed Benefit $40 Copay Deductible then 20% of Allowed Benefit Deductible then $150 Copay (copay waived if admitted) Deductible then $250 Copay Deductible then 20% of Allowed Benefit Deductible then $100 Copay Deductible then 20% of Allowed Benefit

$10 Copay $25 Copay $45 Copay $25 Copay $45 Copay 2 X Retail Copay

Medical Per Pay Costs (2x for monthly cost)

Employee Contribution

Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$50.00 $80.00 $70.00 $87.50

SANS Contribution $345.77 $829.71 $661.07 $1,021.47 New in 2022- Medical will no longer be bundled with dental. If you want medical and dental, you will need to elect both separately. Overall total costs will remain the same in 2022.