Employer Group Plan (Groups 1-50) 2015 Plan Benefit Highlights PLAN NAME Ruby 40 SERVICES AND FEATURES Annual Deductible Out–of–Pocket Limit On Expenses LIFETIME MAXIMUMS PROFESSIONAL SERVICES $0 Individual $6,000 / Family $12,000 No Limit Member Cost Share Preventive Care/ Screening/Immunization $0 Copay Primary Care Visit to Treat an Injury or Illness $40 Copay Specialist Visit $40 Copay Maternity Care - Prenatal and Postnatal Care (Does Not Include Delivery and Inpatient Services) $0 Copay OUTPATIENT SERVICES Laboratory Tests & X-Rays Imaging (CT/PET Scans, MRIs) Surgery - Facility/Physician/Surgery Fees (e.g., Ambulatory Surgery Center $0 Copay $150 Copay $100 (Chinese Hospital) / $300 (Other Contracted Facilities) HOSPITALIZATION SERVICES Facility Fee (e.g., Hospital Room) $250 Copay Per Day (Chinese Hospital) / $750 Copay Per Day (Other Contracted Facilities) (Up to First 5 days) EMERGENCY HEALTH COVERAGE Emergency Room Services $200 Copay Urgent Care $40 Copay PRESCRIPTION DRUG COVERAGE Annual Brand Name / Specialty Prescription Rx Deductible (D1) Generic Drugs (30-Day Supply) Individual $250 / Family $500 Brand Name / Specialty Prescription Rx (D1) $15 Copay Preferred Brand Drugs (30-Day Supply) $50 Copay (After Rx Deductible) Non-preferred Brand Drugs (30-Day Supply) $70 Copay (After Rx Deductible) Specialty Drugs (30-Day Supply) 20% Coinsurance (After Rx Deductible) PEDIATRIC VISION AND DENTAL (Included in Plan) Child Needs Eye Care (Ages 0-18) Eye Exam (1 Per Calendar Year) $0 Copay Eyewear (Frames) (1 Pair Per Calendar Year) $0 Copay Eyewear (Lenses) (1 Pair Per Calendar Year) Single Vision / Bi-focal / Tri-focal / Lenticular No Cost Share Eyewear (Contact Lenses) $0 Copay Pediatric Dental (Ages 0-18) Included in Plan. See Dental Summary Page. Footnotes: (D1) For brand name and specialty prescription drugs only.