Important Questions Answers Why this Matters:

Martin Memorial Health Systems, Inc. Health Plan: Martin Benefit Plan Coverage Period: 10/01/2014-9/30/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single + Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mmhshealthplan.com or by calling your employer at 772-223-5945x2222 or Coordinated Health/Care at 866-521-0160. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan For domestic providers: $600 person / $1,800 family; For participating providers $600 person / $1,800 family; For nonparticipating providers: $800 person / $2,400 family No. Yes. For domestic providers $3,500 person / $10,500 family For participating providers $4,000 person / $12,000 family For non-participating providers No Limit Prescription drug copays, premiums, precertification penalty amounts, balancebilled charges and health care this plan No. Yes. See www.mmhshealthplan.com or www.aetna.com/docfind/custom/my meritain or call 866-521-0160 for a list of participating providers. No. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, October 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term innetwork, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. page 5. See your policy or plan document for additional information about excluded services. Questions: Call your employer at 772-223-5945x2222 or Coordinated Health/Care at 866-521-0160 or visit us at www.mmhshealthplan.com. www.dol.gov/ebsa/pdf/sbcuniformglossary.pdf or call your employer at 772-223-5945x2222 to request a copy. 1 of 8

Common Medical Event If you visit a health care or clinic If you have a test If you need drugs to treat your illness or Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you deductible. The amount the plan pays for covered services is based on the allowed amount. If a non-participating provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-participating provider hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use domestic providers by charging you lower deductibles, copayments and coinsurance amounts. Domestic Non- (Martin Participating Participating Memorial) Services You May Need Primary care visit to treat an injury or an illness Specialist visit Other practitioner office visit Preventive care/ screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Generic drugs $25 copay/office visit charge/20% coinsurance (all other services) $25 copay/office visit charge (with PCP referral)/$30 copay/office visit charge (without PCP referral)/20% coinsurance (all other services) Not applicable for chiropractor / $25 copay/visit for acupucture $30 copay/office visit charge/30% coinsurance (all other services) $25 copay/office visit charge (with PCP referral)/$50 copay/office visit charge (without PCP referral)/ 30% coinsurance (all other services) $35 copay/visit for chiropractor Acupuncture not covered Limitations & Exceptions 50% coinsurance Copay applies to the physician office visit only. Deductible does not apply to the office visit charge for domestic and participating providers. 50% coinsurance Not covered for chiropractor or acupuncture Deductible does not apply for domestic and participating providers. Chiropractic care limited to 26 visits per year. No Charge No Charge 50% coinsurance Deductible does not apply for domestic or participating providers. 20% coinsurance 30% coinsurance 50% coinsurance ----------------none---------------- 20% coinsurance 30% coinsurance 50% coinsurance Precertification required. Failure to precertify will result in a $500 penalty Greater of 10% or Greater of 20% or Not Covered The deductible does not apply. Covers up to $12 copay (retail) / $15 copay (retail) / a 30-day supply (retail prescription); 90-day greater of 10% or greater of 20% or supply (mail order prescription). Copay 2 of 8

Common Medical Event condition. More information about prescription drug coverage is available at www.mmhshealth plan.com If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, Services You May Need Domestic (Martin Memorial) Participating $24 copay (mail Non- Participating Limitations & Exceptions $24 copay (mail applies per prescription. Prescription drugs have a separate out-of-pocket limit of $2,500 Preferred brand drugs Greater of 20% or Greater of 30% or Not Covered per individual and $7,500 per family. Once $20 copay (retail) / $30 copay (retail) / the out-of-pocket limit is reached prescription Greater of 15% or Greater of 15% or drugs are paid at 100%. $40 copay (mail $40 copay (mail Non-preferred brand Greater of 40% or Greater of 50% or Not Covered drugs $40 copay (retail) / $50 copay (retail) / greater of 25% or greater of 25% or $80 copay (mail $80 copay (mail Specialty drugs $150 copay (retail $150 copay (retail Not Covered Limited to a 30-day supply only) only) Facility fee (e.g., 20% coinsurance 30% coinsurance 50% coinsurance Precertification required unless performed in ambulatory surgery center) an office setting. Failure to precertify will Physician/surgeon fees 20% coinsurance 30% coinsurance 50% coinsurance result in a $500 penalty. Emergency room services $150 copay/visit $150 copay/visit $150 copay/visit Deductible does not apply for emergency (medical emergency) (medical emergency) (medical emergency) services for an emergency medical condition. / $200 copay/visit / $200 copay/visit / $200 copay/visit + 30% coinsurance + 30% coinsurance + 30% coinsurance (non-medical (non-medical (non-medical emergency) emergency) emergency) Emergency medical 20% coinsurance 20% coinsurance 20% coinsurance ----------------none---------------- transportation Urgent Care $25 copay/visit $50 copay/visit 50% coinsurance Deductible does not apply for domestic or participating providers. Facility fee (e.g., hospital $100 copay/ $500 copay/ $1,000 copay/ Precertification required. Failure to precertify room) admission + 20% admission + 30% admission + 50% will result in a $500 penalty. coinsurance coinsurance coinsurance Physician/surgeon fee 20% coinsurance 30% coinsurance 50% coinsurance Mental/Behavioral health $25 copay/visit $30 copay/visit outpatient services (office visit)/20% (office visit)/30% 50% coinsurance Deductible does not apply for domestic or participating provider office visits. 3 of 8

Common Medical Event behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Domestic Non- Services You May (Martin Participating Participating Need Memorial) Limitations & Exceptions coinsurance (all coinsurance (all other outpatient) other outpatient) Mental/Behavioral health $100 copay/ $500 copay/ $1,000 copay/ Precertification required. Failure to precertify inpatient services admission + 20% admission + 30% admission + 50% will result in a $500 penalty. coinsurance coinsurance coinsurance Substance use disorder $25 copay/visit $30 copay/visit 50% coinsurance Deductible does not apply for domestic or outpatient services (office visit)/20% (office visit)/30% participating provider office visits. coinsurance (all coinsurance (all other outpatient) other outpatient) Substance use disorder $100 copay/ $500 copay/ $1,000 copay/ Precertification required. Failure to precertify inpatient services admission + 20% admission + 30% admission + 50% will result in a $500 penalty. coinsurance coinsurance coinsurance Prenatal and postnatal $25 copay (initial $30 copay (initial 50% coinsurance There is no charge and the deductible does care visit) / 20% visit) / 30% not apply to preventive prenatal care and coinsurance (all coinsurance (all certain breastfeeding support and supplies other care) other care) from a participating provider. Delivery and all inpatient $100 copay/ $500 copay/ $1,000 copay/ Precertification required for inpatient services admission + 20% admission + 30% admission + 50% Hospital stays in excess of 48 hrs (vaginal coinsurance (facilty coinsurance (facilty coinsurance (facilty delivery) or 96 hrs (c-section). Failure to charges) / 20% charges) / 30% charges) / 50% precertify will result in a $500 penalty. coinsurance coinsurance coinsurance (professional fees) (professional fees) (professional fees) Home health care 20% coinsurance 30% coinsurance 50% coinsurance Limited to 100 visits per year. Precertification required. Failure to precertify will result in a $500 penalty. Rehabilitation services $25 copay/visit Not Covered Not Covered Includes physical, speech & occupational therapy. Limited to 26 visits per year per therapy. Habilitation services $25 copay/visit Not Covered Not Covered ----------------none---------------- Skilled nursing care 20% coinsurance 30% coinsurance 50% coinsurance Limited to 120 days per year. Precertification required. Failure to precertify will result in a $500 penalty. Durable medical equipment 20% coinsurance 30% coinsurance 50% coinsurance Precertification required for any item in excess of $500. Failure to precertify will result 4 of 8

Common Medical Event If your child needs dental or eye care Services You May Need Domestic (Martin Memorial) Participating Non- Participating Limitations & Exceptions in a $500 penalty. Hospice service 20% coinsurance 30% coinsurance 50% coinsurance Bereavement counseling is only covered if received within 6 months of death. Precertification required. Failure to precertify will result in a $500 penalty. Eye exam Not Covered Not Covered Not Covered Not Covered Glasses Not Covered Not Covered Not Covered Not Covered Dental check-up Not Covered Not Covered Not Covered Not Covered Excluded Services & Other Covered Services: services.) Cosmetic surgery Dental care (Adult & Child) Glasses (Adult & Child) Hearing aids Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (Adult & Child) Routine foot care costs for these services.) Acupuncture (covered only at Martin) Bariatric surgery (for the treatment of morbid obesity only) Infertility treatment Chiropractic care Weight loss programs (for the treatment of morbid obesity only) 5 of 8

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 772-223-5945x2222 or Coordinated Health/Care at 866-521-0160. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Martin Memorial Health Systems, Inc. at 772-223-5945x2222, Coordinated Health/Care at 866-521-0160 or -866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Does this Coverage Provide Minimum Essential Coverage? This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: (Español): Para obtener asistencia en Español, llame al 1-800-378-1179. (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-378-1179. (Chinese): (): 1-800-378-1179. (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-378-1179. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

Martin Memorial Health Systems, Inc. Health Plan: Martin Benefit Plan Coverage Period: 10/01/2014-9/30/2015 Coverage Examples Coverage for: Single + Family Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $5,360 Patient pays $2,180 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,810 Patient pays $1,590 Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $600 Patient pays: Copays $680 Deductibles $600 Coinsurance $230 Copays $120 Limits or exclusions $80 Coinsurance $1,310 Total $1,590 Limits or exclusions $150 Total $2,180 7 of 8

Martin Memorial Health Systems, Inc. Health Plan: Martin Benefit Plan Coverage Period: 10/01/2014-9/30/2015 Coverage Examples Coverage for: Single + Family Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? premiums. Sample care costs are based on national averages supplied by the U.S. Department specific to a particular geographic area or health plan. Coverage examples are based on single coverage only. was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from domestic providers. If the patient had received care from participating or nonparticipating providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans find the same Coverage Examples. When you compare plans number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, -of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call your employer at 772-223-5945x2222 or Coordinated Health/Care at 866-521-0160 or visit us at www.mmhshealthplan.com. www.dol.gov/ebsa/pdf/sbcuniformglossary.pdf or call your employer at 772-223-5945x2222 to request a copy. 8 of 8