Option and Cost-Sharing Table

MEDICA OPTION AND COST-SHARING TABLE

THIS AMENDMENT APPLIES TO SERVICES ON AND AFTER JANUARY 1, 2003 . ACTIVE EMPLOYEES AND THEIR COVERED DEPENDENTS

. RETIREES, DISABLED FORMER EMPLOYEES AND THEIR COVERED DEPENDENTS NOT ELIGIBLE FOR MEDICARE

. RETIREES, DISABLED FORMER EMPLOYEES AND THEIR COVERED DEPENDENTS ELIGIBLE FOR MEDICARE MEDICA OPTION AND COST-SHARING TABLE

MEDICA CHOICE CLASSIC Beginning for services received on or after January 1, 2003, benefit levels for network care will be the same – whether you refer yourself to network providers or a Primary Care Provider (PCP) at your Primary Care Clinic (PCC) directs your care. In other words, you no longer will see a distinction between Tier I and Tier II benefits. The product name is “Medica Choice Classic.” It is an open access plan. Open access means that referrals are not mandatory – though it is still recommended that you maintain an ongoing relationship with a PCC/PCP.

The following notations in the Self-Insured Managed-Care Option for Unisys Participants in Designated Geographic Locations Supplement to the Summary Plan Description for Medial plans sponsored by Unisys no longer will apply for services on and after January 1, 2003: . Note for Medica Self-Insured: Medica allows you to refer yourself to network providers without referral from your PCC. This is called “self-referral.” Tier II benefits apply for all covered services directly from the self-referral provider as well as all covered services ordered or coordinated by the self-referral provider. Copayments and coinsurance are higher under Tier II than when you obtain a referral from your PCC (Tier I). . Sentence two of Paragraph two before the Cost-Sharing Table that begin on page 30 of the Supplement Tier II benefits apply for all covered services received directly from the self-referral provider, as well as all covered services ordered or coordinated by the self-referral provider. . The Cost-Sharing table shown on pages 30 to 37. This table is replaced with the following Cost-Sharing Table.

STANDARD OFFICE VISIT COPAYMENTS With this change is a standardization of copayments for office visits: . $10/visit to a network primary care physician – a Family Practice Physician, an Internist, a Pediatrician or a General Practice Physician . $15/visit to a network specialist.

MAXIMUM OUT-OF-POCKET COST PROTECTION Effective retroactive to services provided on or after January 1, 2002, a $750 per person annual out-of-pocket maximum applies. . For services received in 2002, the maximum applies to Tier I benefits – services provided by or directed by your PCC/PCP (out-of-pocket costs noted below do not count toward the annual out-of-pocket maximum) . For services received on or after January 1, 2003, the maximum applies to your share of all covered services.

Once you reach your annual out-of-pocket maximum, the Plan pays 100 percent of covered expenses

There is no out-of-pocket maximum protection for the expenses noted below. In other word, these expenses are not paid at 100 percent once the annual out-of-pocket maximum is met. . Copayments for prescription drugs or the difference between a brand-name price and the established generic unit price when a generic drug is available . Charges for services that are not medically necessary. . Expenses not covered under the Plan. . The $10 or $15 copayment for covered visits to a network physician or urgent care center. MEDICA OPTION AND COST SHARING TABLE

MEDICA COST-SHARING TABLE The following chart outlines benefits for those enrolled in the Medica option as an active employee, a retiree, a disabled former employee, or an enrolled dependent of an active employee, retiree, or disabled former employee.

For retirees, disabled former employees, and their covered dependents eligible for Medicare, plan benefits are payable after copayments and Medicare payments are considered.

This chart is just a summary of the benefits. Some services may have limits. Specific conditions, limits and exclusions are detailed in the Supplement.

MEDICA OPTION AND COST-SHARING TABLE

MEDICA COST-SHARING TABLE Feature Cost-Sharing for services on or after 1/01/2003 Annual Deductible None $750 Annual Out-of-Pocket Limit see exclusions noted above Lifetime Maximum Benefit None If required, network provider handles for you, except treatment for medical emergency or urgent medical need Precertification when care is received outside the Medica service area by a non-network provider Network Physician Visits for Preventive Services . Well-child care; frequency/type based You pay $10/visit to PCC/PCP or $15/visit to a specialist, on Medica then Plan pays 100% . Routine visits, age 18 and older You pay $10/visit to PCC/PCP or $15/visit to a specialist, (annual) then Plan pays 100% . Well-woman exam (annual) You pay $10/visit to network OB/GYN, then Plan pays 100% . Prenatal care You pay $15 for first office visit to network OB/GYN, then Plan pays 100% for all prenatal care thereafter . Cancer screenings (physician services You pay $10/visit to PCC/PCP or $15/visit to specialist, only); frequency/type based on Medica then Plan pays 100% guidelines . Vision . Examination by network You pay $15/visit, optometrist or ophthalmologist; no then Plan pays 100% referral required; frequency based on Medica guidelines . Eyewear Not covered; Discount arrangements are available through the Plan Network Physician Visits Other Than Preventive Services . Treatment of illness or injury You pay $10/visit to PCC/PCP or $15/visit to specialist, then Plan pays 100% . Office surgery You pay $10/visit to PCC/PCP or $15/visit to specialist, then Plan pays 100% . Office lab and x-ray . Billed with office visit Plan pays 100% . No office visit when services Plan pays 100% rendered . Allergy testing and treatment You pay $10/visit to PCC/PCP or $15/visit to specialist, then Plan pays 100% Network Convenient/Urgent Care Centers . Services after normal PCC hours You pay $10/visit, then Plan pays 100% Inpatient Network Hospital Services MEDICA OPTION AND COST SHARING TABLE

MEDICA COST-SHARING TABLE Feature Cost-Sharing for services on or after 1/01/2003 . Hospital semi-private room & board You pay $250/admission, and ancillary services (not applicable for re-admission within 30 days for the same condition; $750 maximum/person/year), then Plan pays 100% . Lab and x-ray Plan pays 100% after the hospital copayment . Surgeons' charges Plan pays 100% after the hospital copayment . Physician hospital visits Plan pays 100% after the hospital copayment . Anesthesia Plan pays 100% after the hospital copayment . Delivery — normal or C-section Plan pays 100% after the hospital copayment Network Alternatives to Inpatient Care . Skilled nursing facility You pay 20%, (maximum of 90 days/lifetime) then Plan pays 80%; after out-of-pocket maximum met, Plan pays 100% You pay 20%, then Plan pays 80%; . Home-health care after out-of-pocket maximum met, Plan pays 100%; For high-risk prenatal care, Plan pays 100% You pay 20%, . Home IV therapy then Plan pays 80%; after out-of-pocket maximum met, Plan pays 100% . Inpatient hospice for palliative care of Plan pays 100% terminally ill Outpatient Services (treatment and services by network providers performed in a network facility other than in the physician’s office or as an inpatient in a network hospital) . Surgery, including surgeon You pay $100/procedure, and facility then Plan pays 100% You pay $15/test or x-ray, . Independent lab and x-ray facilities then Plan pays 100% . Hospital emergency room (medical emergency defined on page 52 of the Supplement) . For treatment of a medical You pay $50/visit emergency (waived if admitted within 24 hours for the same condition), then Plan pays 100%

. For non-emergency care not Not covered authorized in advance by PCC/PCP . Hospital observation room for up to 24 You pay $100, hours without admission then Plan pays 100% . Follow-up care with PCC/PCP or You pay $10/visit for PCC/PCP or $15/visit for specialist, referral specialist then Plan pays 100% . Ambulance (see definitions of ambulance, page 50, and medical MEDICA OPTION AND COST-SHARING TABLE

MEDICA COST-SHARING TABLE Feature Cost-Sharing for services on or after 1/01/2003 emergency, page 52 of the Supplement) . For a medical emergency You pay 20%, then Plan pays 80%; after out-of-pocket maximum met, Plan pays 100% . For non-emergency transportation You pay 20%, approved by Medica and then Play pays 80%; recommended by a network after out-of-pocket maximum met, Plan pays 100% provider otherwise, not covered Network Treatment for Mental Health Conditions by Network Providers: must be precertified by UBH @ 1-800-848-8327 . Inpatient hospital or specialized You pay standard hospital copayment, treatment facility then Plan pays 100%; up to 30 days/year, up to 90 days/lifetime; annual and lifetime maximums include inpatient care for detoxification and treatment of substance abuse conditions; each day in a partial-day treatment program counts as an inpatient day . Physician inpatient visits Plan pays 100%, up to 30 days/year, up to 90 days/lifetime; annual and lifetime maximums include inpatient care for detoxification and treatment of substance abuse conditions . Office/outpatient visits You pay $15/visit, then Plan pays 100%; up to 30 visits/year (individual, family, group or other visits count as one visit) Network Treatment for Substance Abuse Conditions by Network Providers: must be precertified by UBH @ 1-800-848-8327 . Detoxification You pay standard hospital copayment, then Plan pays 100% . Inpatient hospital or specialized You pay standard hospital copayment, treatment facility then Plan pays 100%; up to 30 days/year, up to 90 days/lifetime; annual and lifetime maximums include inpatient care for detoxification and treatment of mental health conditions; each day in a partial-day treatment program counts as an inpatient day . Physician inpatient visits Plan pays 100%; up to 30 days/year, up to 90 days/lifetime; annual and lifetime maximums include inpatient care for detoxification and treatment of mental health conditions . Outpatient visits You pay $15/visit for referral specialist, then Plan pays 100%; up to 30 visits/year; (individual, family, group or other visits count as one visit) MEDICA OPTION AND COST SHARING TABLE

MEDICA COST-SHARING TABLE Feature Cost-Sharing for services on or after 1/01/2003 Other Network Services and Supplies . Acupuncture You pay $10/visit to PCC/PCP or $15/visit to a network only medically necessary services specialist M.D., then Plan pays 100%; maximum 15 visits per year . Chiropractic services You pay $15/visit for network provider, . Only for short-term treatment when there is a then Plan pays 100%; reasonable expectation that a condition will improve over a short-predictable period of time up to 15 visits within 60 consecutive days/incidence, . Does not include maintenance or palliative measured from start of treatment; care Medica Medical Director can authorize additional therapy, provided the conditions noted to the left continue to apply . Communication or interpretation Plan pays 100%, services for a ventilator-dependent up to 120 hours/lifetime patient during an inpatient stay . Dental services Limited to: . surgical procedures commonly viewed as medical rather than dental in nature (same benefits as other outpatient surgery) . certain services or supplies for an accidental injury to sound natural teeth if the service is done or supply provided as part of the initial emergency treatment (same benefits as other emergency treatment) Other dental procedures are not covered . Diabetes self-management training and You pay $10/visit to PCC/PCP or $15/visit to specialist, education then Plan pays 100% . Medical nutrition therapy . Program consistent with national standards established by the American Diabetes Association

. Durable medical equipment (DME) Plan pays 100% for initial DME; For replacement, repair, or revision of artificial eyes, limbs, and breast prosthesis made necessary by normal wear and usage, you pay 20%, then Plan pays 80%; after out-of-pocket maximum met, Plan pays 100% . Infertility treatments: Covered the same as treatment for other conditions limited to the diagnosis and treatment of medical conditions resulting in infertility and treatment to return the body to normal bodily function . Miscellaneous covered medical You pay 20%, services – some examples include, but then Plan pays 80%; are not limited to: after out-of-pocket maximum met, Plan pays 100% . Blood clotting factors (Factors VIII and IX) . Levonorgestrel (i.e. Norplant); limited to 1 implant every 3 years . Total parenteral nutrition MEDICA OPTION AND COST-SHARING TABLE

MEDICA COST-SHARING TABLE Feature Cost-Sharing for services on or after 1/01/2003 . Nutritional supplements for the You pay 20%, treatment of PKU then Plan pays 80%; after out-of-pocket maximum met, Plan pays 100% . Prosthetic devises; limited to items Plan Pays 100% for covered prosthetic devices when noted on pages 68 and 69 of the obtained from network vendors; Supplement. Covered wigs limited to $350 per year . Reconstructive and restorative surgery Plan pays 100% that is not cosmetic in nature . Rehabilitative services: cognitive, You pay $15/visit, physical, occupational, pulmonary, and then Plan pays 100%; speech therapy up to 15 visits/therapy/condition; Medica Medical . Only for short-term treatment when there is a Director or designee can authorize additional therapy, reasonable expectation that a condition will improve over a short, predictable period of provided the conditions noted to the left continue to time apply . Only to restore function lost through illness or injury . Does not include maintenance or palliative care

. Treatment to lighten or remove the You pay $10/visit to PCC/PCP or $15/visit to a specialist, coloration of a port wine stain then Plan pays 100%