EFCA-Reachglobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 12/31/2013

EFCA-ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, 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.healthscopebenefits.com or by calling 1-800-322-7914.

Important Questions Answers Why this Matters: Outside the United States: $2,500 Individual / $5,000 Family; You must pay all the costs up to the deductible amount before this plan begins to pay What is the overall Network: $2,500 Individual / for covered services you use. Check your policy or plan document to see when the deductible? deductible starts over (usually, but not always, January 1st). See the chart starting on Family; $5,000 page 2 for how much you pay for covered services after you meet the deductible. Non-Network: $2,500 Individual / $5,000 Family Are there other You don’t have to meet deductibles for specific services, but see the chart starting on No. deductibles for specific page 2 for other costs for services this plan covers. services? Outside the United States: Not Is there an out–of– Applicable; The out-of-pocket limit is the most you could pay during a coverage period (usually pocket limit on my Network: Not Applicable one year) for your share of the cost of covered services. This limit helps you plan for expenses? Non-Network: $2,000 health care expenses. Individual / $4,000 Family; Premiums, balance-billed What is not included in charges, deductibles, the out–of–pocket copayments, penalties, and Even though you pay these expenses, they don’t count toward the out-of-pocket limit. limit? health care charges this plan doesn’t cover. Is there an overall The chart starting on page 2 describes any limits on what the plan will pay for specific annual limit on what No. covered services, such as office visits. the plan pays? Does this plan use a Yes. See If you use an in-network doctor or other health care provider, this plan will pay some network of providers? www.healthscopebenefits.com or all of the costs of covered services. Be aware, your in-network doctor or hospital or call 1-800-322-7914 for a may use an out-of-network provider for some services. Plans use the term in-network, list of participating providers. preferred, or participating for providers in their network. See the chart starting on Questions: Call 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 1 of 9 EFCA-ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO page 2 for how this plan pays different kinds of providers. Do I need a referral to No. You don’t need a referral to You can see the specialist you choose without permission from this plan. see a specialist? see a specialist. Are there services this Some of the services this plan doesn’t cover are listed on page 5. See your policy or Yes. plan doesn’t cover? plan document for additional information about excluded services.

 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 plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network 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 In-Network providers by charging you lower deductibles, copayments and coinsurance amounts.

Your Cost If You Your Cost If You Your Cost If You Common Services You May Use an Use an Limitations & are Outside the In-Network Non-Network Medical Event Need United States Exceptions Provider Provider Primary care visit to treat No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– an injury or illness Specialist visit No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– Other practitioner office Chiropractic care: Chiropractic care: Chiropractic care: Chiropractic care: 50 visit visit No coinsurance No coinsurance 20% coinsurance maximum per Calendar If you visit a health Year. $40 Maximum care provider’s Benefit per Visit. office or clinic Preventive care/screening/ No coinsurance, no No coinsurance, no No coinsurance, no –––––––none–––––––– immunization deductible up to deductible up to deductible up to $400, then $400, then $400, then deductible and no deductible and no deductible and 20% coinsurance coinsurance coinsurance

If you have a test Diagnostic test (x-ray, No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– blood work) Questions: Call 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 2 of 9 EFCA-ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO Your Cost If You Your Cost If You Your Cost If You Common Services You May Use an Use an Limitations & are Outside the In-Network Non-Network Medical Event Need United States Exceptions Provider Provider Imaging (CT/PET scans, No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– MRIs) If you need drugs to Generic drugs No coinsurance No coinsurance No coinsurance –––––––none–––––––– treat your illness or Preferred brand drugs No coinsurance No coinsurance No coinsurance –––––––none–––––––– condition Non-preferred brand drugs No coinsurance No coinsurance No coinsurance –––––––none–––––––– More information Specialty drugs No coinsurance No coinsurance No coinsurance –––––––none–––––––– about prescription drug coverage is available at www.catalystrx.com. Facility fee (e.g., No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– If you have ambulatory surgery center) outpatient surgery Physician/surgeon fees No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– Emergency room services No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– If you need Emergency medical No coinsurance No coinsurance 20% coinsurance none–––––––– immediate medical ––––––– transportation attention Urgent care No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– Facility fee (e.g., hospital No coinsurance No coinsurance 20% coinsurance Pre-certification required. If you have a room) hospital stay Physician/surgeon fee No coinsurance No coinsurance 20% coinsurance Pre-certification required. Mental/Behavioral health No coinsurance No coinsurance No coinsurance –––––––none–––––––– outpatient services If you have mental Mental/Behavioral health No coinsurance No coinsurance No coinsurance Pre-certification required. health, behavioral inpatient services health, or substance Substance use disorder Not covered Not covered Not covered Not covered abuse needs outpatient services Substance use disorder Not covered Not covered Not covered Not covered inpatient services If you are pregnant Prenatal and postnatal care No coinsurance No coinsurance 20% coinsurance –––––––none––––––––

Questions: Call 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 3 of 9 EFCA-ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO Your Cost If You Your Cost If You Your Cost If You Common Services You May Use an Use an Limitations & are Outside the In-Network Non-Network Medical Event Need United States Exceptions Provider Provider Delivery and all inpatient No coinsurance No coinsurance 20% coinsurance Pre-certification may be services required. Home health care No coinsurance No coinsurance 20% coinsurance Limited to a $50,000 annual maximum benefit. Rehabilitation services No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– If you need help Habilitation services No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– recovering or have Skilled nursing care No coinsurance No coinsurance 20% coinsurance Limited to a $100,000 other special health annual maximum benefit. needs Durable medical No coinsurance No coinsurance 20% coinsurance –––––––none–––––––– equipment Hospice service No coinsurance No coinsurance 20% coinsurance Limited to a $25,000 annual maximum benefit. Eye exam No coinsurance No coinsurance No coinsurance Limited to $250 annual maximum benefit. One exam every 24 months. Glasses No coinsurance No coinsurance No coinsurance Limited to $250 annual If your child needs maximum benefit. One dental or eye care pair of glasses every 12 months. Dental check-up No coinsurance No coinsurance No coinsurance Limited to $3,000 of benefits every three Calendar Years.

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)  Acupuncture  Infertility treatments  Weight loss programs  Bariatric surgery  Long-term care  Substance abuse  Cosmetic surgery  Routine foot care

Questions: Call 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 4 of 9 EFCA-ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)  Chiropractic care  Hearing aids  Private duty nursing  Dental care (Adult)  Non-emergency care received while  Routine eye care (Adult) traveling outside the U.S.

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 1-800-322-7914. 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: HealthSCOPE Benefits Customer Service at 1-800-322-7914, or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-322-7914.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-322-7914.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-322-7914.

Questions: Call 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 5 of 9 EFCA-ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-322-7914.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

Questions: Call 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 6 of 9 EFCA ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Coverage Examples Coverage for: Individual, Family | Plan Type: PPO

Having a baby Managing type 2 diabetes About these Coverage (normal delivery) (routine maintenance of Examples: a well-controlled condition)

These examples show how this plan might  Amount owed to providers: $7,540  Amount owed to providers: $5,400 cover medical care in given situations. Use  Plan pays $7,090  Plan pays $5,020 these examples to see, in general, how much  Patient pays $450  Patient pays $380 financial protection a sample patient might get if they are covered under different plans. 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 This is Hospital charges (baby) $900 Office Visits and Procedures $700 not a cost Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 estimator. Prescriptions $200 Vaccines, other preventive $100 Don’t use these examples to Radiology $200 Total $5,400 estimate your actual costs Vaccines, other preventive $40 under this plan. The actual Total $7,540 Patient pays: care you receive will be Deductibles $300 different from these examples, Patient pays: Copays $0 and the cost of that care will Deductibles $300 Coinsurance $0 also be different. Copays $0 Limits or exclusions $80 Coinsurance $0 Total $380 See the next page for Limits or exclusions $150 important information about Total $450 these examples.

Questions: Call 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 7 of 9 EFCA ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Coverage Examples Coverage for: Individual, Family | Plan Type: PPO Questions and answers about the Coverage Examples:

What are some of the What does a Coverage Example No. Coverage Examples are not cost assumptions behind the show? estimators. You can’t use the examples to Coverage Examples? For each treatment situation, the Coverage estimate costs for an actual condition. Example helps you see how deductibles, They are for comparative purposes only.  Costs don’t include premiums. copayments, and coinsurance can add up. Your own costs will be different  Sample care costs are based on national It also helps you see what expenses might be depending on the care you receive, the averages supplied by the U.S. left up to you to pay because the service or prices your providers charge, and the Department of Health and Human treatment isn’t covered or payment is reimbursement your health plan allows. Services, and aren’t specific to a limited. particular geographic area or health Can I use Coverage Examples plan.  The patient’s condition was not an Does the Coverage Example to compare plans? excluded or preexisting condition. predict my own care needs? Yes. When you look at the Summary of  All services and treatments started and  ended in the same coverage period. No. Treatments shown are just examples. Benefits and Coverage for other plans, you’ll find the same Coverage Examples.  There are no other medical expenses for The care you would receive for this When you compare plans, check the any member covered under this plan. condition could be different based on “Patient Pays” box in each example. The  Out-of-pocket expenses are based only your doctor’s advice, your age, how smaller that number, the more coverage on treating the condition in the serious your condition is, and many other the plan provides. example. factors.  The patient received all care from in- network providers. If the patient had Are there other costs I should Does the Coverage Example received care from out-of-network consider when comparing providers, costs would have been predict my future expenses? plans? higher. Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You

Questions: Call 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 8 of 9 EFCA ReachGlobal: MAP 2 Health Benefit Plan Coverage Period: 01/01/2013 – 12/31/2013 Coverage Examples Coverage for: Individual, Family | Plan Type: PPO 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 1-800-322-7914 or visit us at www.healthscopebenefits.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.healthscopebenefits.com or call 1-800-322-7914 to request a copy. 9 of 9