MEDICAL SCHEDULE OF BENEFITS Benefit Plan(s) 001 All health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays, Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expenses and Maximums section of this SPD for more details. Benefits listed in this Schedule of Benefits are subject to all provisions of the Plan, including any benefit determination based on an evaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and General Exclusions sections of this SPD for more details. Important: Prior authorization may be required before benefits will be considered for payment. Failure to obtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the UMR CARE section of this SPD for a description of these services and prior authorization procedures. Note: Refer to the Provider Network section for clarifications and possible exceptions to the in-network or out-of-network classifications. If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, it is a combined Maximum Benefit for services that the Covered Person receives from all in-network and out-of-network providers and facilities. IN-NETWORK OUT-OF-NETWORK Annual Deductible Per Calendar Year: Note: Medical And Pharmacy Expenses Are Subject To The Same Deductible. • Single Coverage $3,500 $4,500 • Family Coverage $7,000 $9,000 − Individual Embedded Deductible $3,500 $4,500 Note: Embedded Deductible Means That If You Have Family Coverage, Any Combination Of Covered Family Members May Help Meet The Maximum Family Deductible; However, No One Person Will Pay More Than His Or Her Embedded Individual Deductible Amount. Plan Participation Rate, Unless Otherwise Stated Below: • Paid By Plan After Satisfaction Of Deductible 80% 60% Annual Total Out-Of-Pocket Maximum: Note: Medical And Pharmacy Expenses Are Subject To The Same Out-Of-Pocket Maximum. • Single Coverage $4,500 $9,000 • Family Coverage $7,350 $18,000 − Individual Embedded Out-Of-Pocket Maximum $4,500 $9,000 Note: Embedded Out-Of-Pocket Maximum Means That If You Have Family Coverage, Any Combination Of Covered Family Members May Help Meet The Family Out-Of-Pocket Maximum; However, No One Person Will Pay More Than His Or Her Embedded Individual Out-Of-Pocket Maximum Amount. -4- 7670-00-413597