This Is a General Outline of Your Benefits

Augsburg College Group Number GP851 Effective 01/01/2009 $2300 High Deductible Health Plan – HSA Qualified

Plan Highlights In-network Providers Out-of-Network Providers Copay None None Deductible

$2300 single $2300 single  Calendar year accumulation $4600 family $4600 family  Includes medical and prescription drug services

Out-of-Pocket Maximum

 Includes medical and prescription drug services $2300 single $2300 single $4600 family $4600 family

Individual Lifetime Maximum $5,000,000 per person all networks combined Ambulance Deductible/100% Mental Health and Substance Abuse  Inpatient  Outpatient Deductible/100% Deductible/100%  Office Visit Chiropractic Care

 Office Visit Deductible/100% Deductible/100%  All other Chiropractic services Physical, Occupational and Speech Therapy

 Office Visit and Evaluations Deductible/100% Deductible/100%  All other services Home Health Care

Deductible/100% Deductible/100%

Hospital Services – Inpatient

 Facility services  Professional services Deductible/100% Deductible/100%

Hospital Services – Outpatient

Deductible/100% Deductible/100%  Facility services  Professional services

Maternity

 Prenatal care 100% 100%

(Professional and facility services for delivery are covered under Hospital - Inpatient)

Durable Medical Equipment & Supplies Deductible/100%

1 5/20/08 Physician Services

 Office visit Deductible/100% Deductible/100%  Allergy injections

 All other physicians services, including in office surgery

Preventive Care

 Routine hearing exams  Routine physical exams 100% 100%  Routine gynecological exams  Routine eye exams  Immunizations  Routine cancer screening Prescription Drugs

 Retail Network Pharmacies – 31 day supply Deductible/100%  Member pays the difference if a brand name drug is selected when a generic is available

 Mail Order – Up to a 90 day supply Deductible/100%  Member pays the difference if a brand name drug is selected when a generic is available

Some services do require prior authorization or preadmission notification. Please check your summary plan description or call customer service at 651-662-5001 or 1-866-531-6676 for further details.

If a member chooses to utilize an out of network provider they may be responsible for the difference in cost between the billed charge and the allowed amount or negotiated rate. This difference does not apply to the deductible or out of pocket accumulation.

This is a general outline of your benefits. If there is a discrepancy between this summary and the contract, the contract is considered correct.

2 5/20/08