2025 Medical/Rx Benefit Overview Medical & Prescription Drugs Insured by UMR/CVS Caremark Consumer Driven Health Plan 1 Consumer Driven Health Plan 2 Consumer Driven Health Plan 3 Network Benefits Non-Network Network Benefits Non-Network Network Benefits Non-Network Benefits Benefits Benefits Physician Office Visit 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Specialist Office Visit 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Deductible Embedded Non-Embedded Non-Embedded Single $3,500 $4,500 $2,500 $4,000 $2,000 $3,500 Family $7,000 $9,000 $5,000 $8,000 $4,000 $7,000 Coinsurance (your 20% 40% 20% 40% 20% 40% responsibility) Out-of-Pocket Embedded Embedded* Non-Embedded Maximum Single $4,500 $9,000 $4,000 $8,000 $3,500 $7,000 Family $9,000 $18,000 $8,000 $16,000 $7,000 $14,000 Preventive Care 100% Coverage 40% after Deductible 100% Coverage 40% after Deductible 100% Coverage 40% after Deductible Hospital Services 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Out-Patient Services 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Maternity Services 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Emergency Room 20% after Deductible 20% after Deductible 20% after Deductible Services Urgent Care Centers 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Mental & Nervous In-Patient 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Out-Patient 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Substance Abuse In-Patient 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Out-Patient 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible Retail Prescription Drugs Generic 0% after Deductible 40% after Deductible 0% after Deductible 40% after Deductible 0% after Deductible 40% after Deductible Preferred 40% after Deductible 40% after Deductible 40% after Deductible 40% after Deductible 40% after Deductible 40% after Deductible Non-Preferred 50% after Deductible 40% after Deductible 50% after Deductible 40% after Deductible 50% after Deductible 40% after Deductible Mail Order Prescription Drugs Generic 0% after Deductible Not Covered 0% after Deductible Not Covered 0% after Deductible Not Covered Preferred 40% after Deductible Not Covered 40% after Deductible Not Covered 40% after Deductible Not Covered Non-Preferred 50% after Deductible Not Covered 50% after Deductible Not Covered 50% after Deductible Not Covered Lifetime Maximum Unlimited Unlimited Unlimited * No individual shall incur more than $7,500 of out-of-pocket expenses for covered services. Medical Administration by UMR: UMR has negotiated discounts with a large national network of doctors and hospitals named United Healthcare Choice Plus. You will enjoy the highest level of benefits and the greatest value if you choose to receive care through the Choice Plus Network of providers. While it is not required that you utilize the network, the services you obtain outside of the network will be billed at a greater cost to you. You may log onto www.umr.com for a listing of participating providers. This benefit guide only highlights the benefits available. For a more complete description, see the Plan Certificate. 9 If any conflict should arise between this summary and the Plan, the Plan's Certificate will govern in all cases.