CORRECTIONAL DENTAL ASSOCIATES

OLD VERSES NEW HEALTH PLAN COMPARISON

Plan Design Summary Current Plan New Plan

Physician Services Co-pay / Coverage Co-pay / Coverage

Primary Physician Co-payment $15 $20

Specialist $25 $40

Routine GYN Exam (direct access) $25 $40

Surgical Services $25 $40

Therapy $25 $40

Home Health Care $00 $00

Routine Vision Exam (schedule applies) $25 $40

Mental Health (Non-Serious) $25 co-pay; 20 visits / year $40

Substance Abuse Rehab. 60 Visits > $25 60 Visits > $40

Lab $25 $40

Radiology $25 $40

Ambulance $00 $00

Hospital Services:

Inpatient Acute Care $240 20%

Inpatient Mental Health (35 days per year) $240 20%

Outpatient Surgery Co-pay (SPU) $00 20%

Emergency Room / Urgent Care $50 $50

Referred Out of Pocket Limit $1,500 / $3,000 $1,500 / $3,000

Hospital & SPU Deductible $00 / $00 $500

Pharmacy Plan

Pharmacy Co-payment $15 / $15 Open 34 day $15 / 25 No MG Open 30 day

Mail Order 1x / 2x retail co-pay 1X 2X

Oral Contraceptives Not Covered Not Covered

Performance Rider Not Covered Not Covered

Diabetic Supplies Rx Rider Covered Covered

Formulary (Open / Closed) Open Open

Pharmacy Deductible None None

Riders

Vision Hardware (Coverage / 24 months) Not Covered Not Covered

ART (Fertility) Not Covered Not Covered

Chiropractic Care Co-pay (20 visits / yr) Not Covered $40

Dental Family Rider Not Covered Not Covered

Durable Medical Equipment Covered $00 Co-pay

Open Access Option No No

Out of Network

Deductible $500 / $1,500 $1,000 / $3,000

Coinsurance % 80% / 20% 50% / 50%

Coinsurance Limit (Out of Pocket) $2,500 / $7,500 $10,000 / $30,000

Lifetime Maximum $5,000,000 $5,000,000