MEDICAL BENEFITS

In 2023, SANS will be moving from CareFirst to CareFirst Administrators (CFA) as our medical carrier. All medical and prescription benefits will remain the same but, all members will receive new ID cards from

CFA. Please ensure you give your doctor(s) and pharmacy the new ID card at your first visit after January 1, 2023.

Blue Preferred PPO Plan Highlights

• Utilizes the national BlueCard PPO network • TraditionalPPO with lower deductible • To locate an in-network doctor visit www.cfablue.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.

CareFirst PPO

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 EmergencyRoom 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

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

Employee Contribution

SANS Contribution

Medical Per Pay Costs (2x for monthly cost)

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

$50.00 $80.00 $70.00 $87.50

$362.96 $834.81 $671.48 $1,016.29