MEDICAL

Medical Contributions Per Pay Period
Enhanced Plan Single Family	$88.00 $275.00
Basic Plan Single Family	$63.00 $205.00
HSA Plan Single Family	$45.00 $160.00

OUR MEDICAL PLANS

Provide a wide range of health care services.
Provide benefits for covered expenses after you pay a copayment or meet the applicable annual deductible.
Offer network providers whose pre-negotiated rates will save you money.
Allow you to use out-of-network providers, if you wish.

Learning as much as possible about the plans can help you make more informed choices regarding your needs and those of your covered dependents. Review the Benefits-at-a-glance chart. The chart will help you make an informed decision about the coverage that best meets your needs and those of your covered dependents.

YOUR OPTIONS FOR MEDICAL COVERAGE

Having access to high quality, affordable health care is a great concern for most people. We are pleased to offer team members and their families medical coverage through Medical Mutual. The company pays the majority of the cost of this coverage and offers three plan choices, an Enhanced Plan, Basic Plan, and HSA Plan.

Both of our plans provide high quality, affordable medical care, including doctors’ visits, preventive care, hospitalization and emergency care. Review the benefit summary comparison chart below to learn as much as possible about the plans.

HOW THE PLANS WORK

All three plans are part of the Preferred Provider Organization, administered by Medical Mutual. All give you freedom of receiving care within the network or from out-of-network providers. When you use providers within the network, the plans pay a higher level of benefits and you generally won’t have to file any claims manually.

If you prefer to go out-of-network for medical care, you will be reimbursed at a lower benefit level. You may also have to file a claim for reimbursement.

Please note: If a preferred provider refers you for covered services to another provider (such as a lab or specialist), make sure the provider you have been referred to is also a preferred provider. If the provider you use is not a preferred provider, your out-of pocket costs will be higher, even if you are referred by a preferred provider.

PRESCRIPTION DRUGS

When you enroll in a medical plan, you automatically receive prescription drug coverage. Coverage is provided through Medical Mutual for retail prescriptions and Express Scripts for mail order. If you have your prescription filled at a participating retail pharmacy, you may purchase up to a 30-day supply of covered drugs. At the participating pharmacy, you will need to present your ID card and make the required copayment. You may obtain information on participating pharmacies by visiting the Express Scripts site. The plan also includes a home delivery order service through Express Scripts. If you are taking a medication for an extended period of time, you can purchase up to a 90-day supply of covered drugs through Express Scripts, which will be delivered directly to your home (or your local RiteAid pharmacy). By using the home delivery program, you are able to get a 90-day, rather than a 30-day, supply.

If your Prescription Order is for a Prescription Drug that is available through the Home Delivery Prescription Drug program and you choose not to use the Home Delivery Prescription Drug program, you will be required to pay two times the appropriate Prescription Drug copayment indicated when your Prescription Order is refilled beyond the second time within a 180- day period.

To use the home delivery program, ask your doctor to give you a new prescription for up to a 90-day supply of your regular medication, plus refills, if appropriate. You will receive forms for refills and future prescription orders each time you receive a prescription from the homedelivery service. You can also re-order online at Express Scripts.

Enhanced Plan – Copayments for Prescription Drugs

	Retail 30-day Supply	Mail-Order 90-day Supply
Generic	$10	$20
Brand Name Formulary	$20	$40
Brand Name Non-Formulary	$40	$80

Basic Plan – Copayments for Prescription Drugs

	Retail 30-day Supply	Mail-Order 90-day Supply
Generic	$10	$20
Brand Name Formulary	$20	$40
Brand Name Non-Formulary	$40	$80

HSA Plan – Subject to Medical Deductible

	Retail 30-day Supply	Mail-Order 90-day Supply
Generic	0%, after deductible	0%, after deductible
Brand Name Formulary	0%, after deductible	0%, after deductible
Brand Name Non-Formulary	0%, after deductible	0%, after deductible

MEDICAL BENEFITS-AT-A-GLANCE – ENHANCED PLAN

Types of Service	In-Network You Pay	*Out-of-Network You Pay**
Deductible (per calendar year)
(Individual / Family)	$250 / $500	$250 / $500
Coinsurance Limit (excludes deductible)
(Individual / Family)	$750 / $1,500	$3,250 / $6,500
Out-of-pocket Maximum (includes deductible, coinsurance, and medical/Rx copays)
Individual/Family (per calendar year)	$6,600 / $13,200	Unlimited
Coinsurance	10%	30%
Emergency Services
Emergency – Emergency Room Emergency Services – all other related charges Non-Emergency – Emergency Room Non-Emergency Services – all other related charges	$150 Copayment 10%, after deductible 10%, after deductible 10%, after deductible	$150 Copayment 10% $50 Copayment, waived if admitted then 30% 30%
Mental Health Care, Drug Abuse/Alcoholism
Inpatient Mental Health Care, Drug Abuse and Alcoholism Services Outpatient Mental Health Care, Drug Abuse and Alcoholism Services Biologically Based Mental Illness Services	Benefits paid are based on corresponding medical benefits	Benefits paid are based on corresponding medical benefits
Outpatient and Routine Services
Well Child Health Supervision Examinations Child Health Supervision Immunizations Child Health Supervision Laboratory Services Medically Necessary Office Visits Outpatient Occupational, Physical and Chiropractic Visits Outpatient Speech Therapy Services Outpatient Allergy Testing and Treatments Routine Physical Examinations Routine Testing and Endoscopic Services	$0 Copayment 0% 0% $10 Copayment $10 Copayment $10 Copayment 10% $0 Copayment 0%	50% 50% 30% $10 Copayment, then 30% $10 Copayment, then 30% $10 Copayment, then 30% 50% 50% 30%
Other Services
Ambulance Services Home Health Care Services Hospice Services Immunizations Organ Transplant Services Second Surgical Opinion Services All Other Covered Services	$25 Copayment 10% 10% 10% 10% 0% 10%	$25 Copayment, then 30% 50% 50% 50% $250 Copayment, then 50% 30% 30%

* Out-of-Network reimbursement is based on what the insurance carrier deems as reasonable & customary. You will be responsible for paying the difference between amount billed and reasonable & customary, in addition to the coinsurance levels above.

MEDICAL BENEFITS-AT-A-GLANCE – BASIC PLAN

Types of Service	In-Network You Pay	*Out-of-Network You Pay**
Deductible (per calendar year)
(Individual / Family)	$500 / $1,000	$1,000 / $2,000
Coinsurance Limit (excludes deductible)
(Individual / Family)	$2,000 / $4,000	$4,000 / $8,000
Out-of-pocket Maximum (includes deductible, coinsurance, and medical/Rx copays)
Individual/Family (per calendar year)	$6,600 / $13,200	Unlimited
Coinsurance	20%	40%
Emergency Services
Emergency – Emergency Room Emergency Services – all other related charges Non-Emergency – Emergency Room Non-Emergency Services – all other related charges	$150 Copayment 20%, after deductible 20%, after deductible 20%, after deductible	$150 Copayment 20% $50 Copayment, waived if admitted then 40% 40%
Mental Health Care, Drug Abuse/Alcoholism
Inpatient Mental Health Care, Drug Abuse and Alcoholism Services Outpatient Mental Health Care, Drug Abuse and Alcoholism Services Biologically Based Mental Illness Services	Benefits paid are based on corresponding medical benefits	Benefits paid are based on corresponding medical benefits
Outpatient and Routine Services
Well Child Health Supervision Examinations Child Health Supervision Immunizations Child Health Supervision Laboratory Services Medically Necessary Office Visits Outpatient Occupational, Physical and Chiropractic Visits Outpatient Speech Therapy Services Outpatient Allergy Testing and Treatments Routine Physical Examinations Routine Testing and Endoscopic Services	$0 Copayment 0% 0% $10 Copayment $10 Copayment $10 Copayment 20% $0 Copayment 0%	50% 50% 40% $20 Copayment, then 40% $20 Copayment, then 40% $20 Copayment, then 40% 50% 50% 40%
Other Services
Ambulance Services Home Health Care Services Hospice Services Immunizations Organ Transplant Services Second Surgical Opinion Services All Other Covered Services	$25 Copayment 20% 20% 20% 20% 0% 20%	$25 Copayment, then 40% 50% 50% 50% 50% 40% 40%

* Out-of-Network reimbursement is based on what the insurance carrier deems as reasonable & customary. You will be responsible for paying the difference between amount billed and reasonable & customary, in addition to the coinsurance levels above.

MEDICAL BENEFITS-AT-A-GLANCE – HSA PLAN

Types of Service	In-Network You Pay	*Out-of-Network You Pay**
Deductible (per calendar year)
(Individual / Family)	$3,200 / $6,400	$6,400 / $12,800
Coinsurance Limit (excludes deductible)
(Individual / Family)	$0 / $0	$6,400 / $12,200
Out-of-pocket Maximum (includes deductible, coinsurance, and medical/Rx copays)
Individual/Family (per calendar year)	$3,200 / $6,400	Unlimited
Coinsurance	0%	50%
Emergency Services
Emergency – Emergency Room Emergency Services – all other related charges Non-Emergency – Emergency Room Non-Emergency Services – all other related charges	0%, after deductible 0%, after deductible 0%, after deductible 0%, after deductible	0%, after In-Network deductible 0%, after In-Network deductible 0%, after deductible 0%, after deductible
Mental Health Care, Drug Abuse/Alcoholism
Inpatient Mental Health Care, Drug Abuse and Alcoholism Services Outpatient Mental Health Care, Drug Abuse and Alcoholism Services Biologically Based Mental Illness Services	Benefits paid are based on corresponding medical benefits	Benefits paid are based on corresponding medical benefits
Outpatient and Routine Services
Well Child Health Supervision Examinations Child Health Supervision Immunizations Child Health Supervision Laboratory Services Medically Necessary Office Visits Outpatient Occupational, Physical and Chiropractic Visits Outpatient Speech Therapy Services Outpatient Allergy Testing and Treatments Routine Physical Examinations Routine Testing and Endoscopic Services	0% 0% 0% 0%, after deductible 0%, after deductible 0%, after deductible 0%, after deductible 0% 0%	50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible
Other Services
Ambulance Services Home Health Care Services Hospice Services Immunizations Organ Transplant Services	0%, after deductible 0%, after deductible 0%, after deductible 0%, after deductible 0%, after deductible	50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible 50%, after deductible