Independence @I

Medical Benefit HighlightsPersonal Choice 20/40/70 Haverford College

Covered Services

Benefits per Calendar YearDeductible (Embedded)1

Individual/Family

Out-of-Pocket Maximum (Embedded)2Individual/Family

Coinsurance

Your Costs (You pay)Out-of-NetworkIn-Network

$300/$900 $1 ,500/$4,500

$3,000/$9.0000%

$6.000/$18,000

30%

Preventive ServicesPreventive Care

Preventive ColonascopyPreventive Plus Providers

Hospital Based

In-Network

No charge no deductible

Out-of-Network30% no deductible

No charge no deductibleNo charge no deductible

Not covered30% no deductible

Physician ServicesPrimary Care Physician (PCP) Office Visit

Specialist Office VisitRetail Health Clinic Visit

Urgent Care Visit

In-Network$20 no deductible

$40 no deductible$20 no deductible

$105 no deductible

Out-of-Network30% after deductible

30% after deductible

30% after deductible

30% after deductible

Virtual Care3Telemedicine

TeledermatologyTelebehavioral Health

In-Network$40 no deductible

$40 no deductible$40 no deductible

Out-of-NetworkNot coveredNot coveredNot covered

Therapy ServicesPhysical Therapy (60 visits/year)4

Freestanding

Hospital BasedOccupational Therapy (60 visits/year)4

Freestanding

Hospital BasedSpeech Therapy (60 visits/year)4

In-Network Out-of-Network

$40 no deductibleNot covered

30% after deductible

30% after deductible

$40 no deductibleNot covered

$40 no deductible

30% after deductible

30% after deductible

30% after deductible

Emergency ServicesEmergency Room (copay waived ifadmitted)

Emergency AmbulanceNon-Emergency Ambulance

In-Network$150 no deductible

Out-of-NetworkCovered at In-Network level

No charge after deductibleNo charge after deductible

Covered at In-Network level

30% after deductible

Reference ID: 1004082501012021

Independence @I

Hospital ServicesInpatient Hospital Services (In-Network:365 days/year; Out-of-Network: 70 days/year)5Observation ServicesMaternity Hospital Services5Inpatient Professional Services (includesMaternity)

In-Network$150/Admission no deductible

Out-of-Network30% after deductible

No charge no deductible$150/Admission no deductible

No charge no deductible

30% after deductible

30% after deductible

30% after deductible

Outpatient SurgeryFreestanding

Hospital BasedOutpatient Professional Services

In-Network$150 no deductible

$150 no deductible

No charge no deductible

Out-of-Network

30% after deductible30% after deductible

30% after deductible

Outpatient DiagnosticsDiagnostic Medical (EKG)

Routine Radiology (X-Ray)

Freestanding

In-Network$40 no deductible

Out-of-Network30% after deductible

$40 no deductible$40 no deductible

30% after deductible

30% after deductibleHospital BasedAdvanced Imaging (MRI/MRA,CT/CTAScan, PET Scan)

Freestanding

Hospital Based$40 no deductible

$40 no deductible30% after deductible

30% after deductible

Outpatient Lab and PathologyFreestanding

Hospital Based

In-Network

No charge after deductibleNo charge after deductible

Out-of-Network

30% after deductible

30% after deductible

Other Medical Services

Spinal Manipulations (30 visits/year)6

Acupuncture (18 visits/year)6Standard Injectables

In-Network$40 no deductible$40 no deductible

No charge no deductible

No charge after deductible

Out-of-Network30% after deductiblb

30% after deductible

30% after deductible

30% after deductibleAllergy Injections

Biotech/Specialty InjectablesHome/Office

Outpatient

Chemotherapy

Dialysis

Skilled Nursing Facility (120 days/year)6Home Health

Hospice

Durable Medical Equipment (DME)

No charge no deductibleo

No charge after deductibleNo charge after deductibleNo charge after deductibleNo charge no deductibleNo charge no deductible$40 no deductible

30% after deductible30% after deductible

30% after deductible

30% after deductible30% after deductible

30% after deductible

30% after deductible

30% after deductible

Reference ID: 1004082501012021

Independence @I

Mental Health - Outpatient (includesserious mental illness and substanceabuse)

$40 no deductible 30% after deductible

Mental Health - Inpatient (includesserious mental illness and substanceabuse)5

$150/Admission no deductible 30% after deductible

1

2

3

4

5

6

Embedded deductible: Each covered family member only needs to satisfy his or her individual deductible, not the entire family deductible, prior toreceiving plan benefits,

Embedded out-of-pocket maximum: Each covered family member only needs to satisfy his or her individual out-of-pocket maximum, not the entirefamily out-of-pocket maximum

Telemedicine is provided by a designated telemedicine provider, please visit www.ibx.com/findcarenow

Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Therapy combined visit limit in and out-of-network

Inpatient hospital out-of-network day limit combined for all inpatient medical, maternity, mental health, serious mental illness, and substance abuseservices

Combined in and out-of-network

The Personal Choice(D Preferred Provider Organization (PPO) gives you freedom of choice by allowing you to select your own doctors and hospitals,You maximize your coverage by accessing care through Personal Choice's network of hospitals, doctors, and specialists, or by accessing care throughpreferred providers who participate in the BlueCard® PPO program. If you access care from a provider who does not participate in our network, you willhave higher out-of-pocket costs and may have to submit your claim for reimbursement,

This summary represents only a partial listing of benefits and exclusions of the Medical Program described in this summary. If your employerpurchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. As a result,this managed care plan may not cover all of your health care expenses. Read your contract/member benefit booklet carefully for a complete listing ofterms, limitations, and exclusions of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visitwww.ibx.com/LGBooklet or call 1-800-ASK-BLUE (TTY: 711 )

Benefits may be changed by Independence Blue Cross to comply with applicable federal/state laws and regulations

Certain services require preapproval/precertification by the health plan prior to being performed. To obtain a list of services that require authorizationplease log on to http://www.ibx.com/preapproval or call the phone number that is listed on the back of your identification card

Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Cross - Independent licensees of the BlueCross and Blue Shield Association. www.ibx.com

Reference ID: 1004082501012021

Independence @I

Drug Benefit HighlightsSelect Drug Program $20/$40/$80.. Haverford College

Covered Services

Benefits per Calendar YearDeductible

Individual/FamilyOut-of-Pocket Maximum

Individual/Family

Formulary

Your Costs (You pay)Out-of-Network$0/$0

In-Network$0/$0

Combined with Medical Combined with Medical

Select

Retail PharmacyTier 1 Generic DrugsTier 2 Preferred Brand

Tier 3 Non-Preferred DrugsDispensing Limits

In-Network$20

$40

$80

30 day supply max

Out-of-Network30% Reimbursement

30% Reimbursement

30% Reimbursement

30 day supply max

Mail Order PharmacyAvailable for maintenance drugsTier 1 Generic DrugsTier 2 Preferred Brand Drugs

Tier 3 Non-Preferred Drugs

Dispensing Limits1

In-Network Out-of-Network

$40

$80

$160

90 day supply max

Not covered

Not covered

Not covered

Not covered

Drug CoverageACA Preventive Drugs2Compound Medications

Contraceptives

Diabetic Supplies (i.e., test strips)

Glucometers (no copayment/coinsurance requiredat participating pharmacies)Insulin

Insulin Needles and Syringes

Lancets (no copaymenUcoinsurance required atparticipating pharmacies)

Prescribed Tobacco Cessation Drugs (RX and OTC)

Retin-A (up to Age 35)

Allergy Serum

Biologicals, InvestigationaMExperimental DrugsBlood. Blood Plasma

Drugs used for Cosmetic PurposesImmunization Agentsr

In-NetworkCovered

Covered

Covered

Covered

Covered

Out-of-NetworkCovered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Covered

Covered

Not coveredNot coveredNot covered

Not covered

Not covered

Not covered

Reference ID: 1004082601012021

Independence @I

Non-Federal Legend Drugs Not covered Not coveredNot coveredOver-The-Counter Drugs (Non-Prescription) Not covered

Not coveredWeight Control Drugs Not covered

1

2

Up to a 90-day supply of drugs to treat chronic conditions available at any participating retail pharmacy or mail for same cost share

Certain designated preventative medications will not be subject to any cost-sharing or deductibles, but will be subject to the terms and conditionsof your benefits contract. Refer to your summary of benefits, member handbook, and/or benefit booklet to determine if your plan includes 100percent coverage for in-network preventive services.

This summary represents only a partial listing of benefits and exclusions of the Prescription Drug Program described in this summary. If your employerpurchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by pharmacy policy. As aresult, this program may not cover all of your health care expenses. Read your contract/member benefit booklet carefully for a complete listing ofterms, limitations, and exclusions of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visitwww.ibx.com/LGBooklet or call 1-800-ASK-BLUE (TTY: 711 )

Any prescription refilled in excess of the number of refills specified by the physician, or any refill dispensed after one year from the physician's originalorder are not covered. Devices or supplies except those specifically listed under covered drugs are not covered. Drugs used to treat hemophilia arenot covered

All covered self-administered specialty medications except insulin will be provided through the convenient Specialty Pharmacy Program for theappropriate cost sharing indicated above. If your doctor wants you to start the drug immediately, an initial 30-day supply may be obtained at a retailpharmacy. However, all subsequent fills must be purchased through the Specialty Pharmacy Program

FutureScripts® network includes more than 65,000 retail pharmacies. You can locate a participating pharmacy near you on www.ibx.com byselecting the Find a Participating Pharmacy featureFutureScripts® is an independent company providing pharmacy benefit management service.

Benefits underwritten or administered by QCC Insurance Company. a subsidiary of Independence Blue Cross - Independent licensees of the BlueCross and Blue Shield Association. www.ibx.com

Reference ID: 1004082601012021

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Y0041 HM 17 47643 Accepted 10/14/2016 Taglines as of 1 0/14/2016

Discrimination is Against the Law

This Plan complies with applicable Federal civil rightslaws and does not discriminate on the basis of race,color, national origin, age, disability, or sex. This Plandoes not exclude people or treat them differentlybecause of race, color, national origin, age, disability,or sex,

If you need these services, contact our Civil RightsCoordinator. If you believe that This Plan has failedto provide these services or discriminated in anotherway on the basis of race, color, national origin, age,disability, or sex, you can file a grievance with our CivilRights Coordinator. You can file a grievance in thefollowing ways: in person or by mail: ATTN: CivilRights Coordinator, 1 901 Market Street,Philadelphia, PA 19103, By phone: 1-888-377-3933 (TTY: 711) By fax: 215-761-0245, By email:civilrightscoordinator@ 1901 market.com. If you needhelp filing a grievance, our Civil Rights Coordinator isavailable to help you.

This Plan provides:• Free aids and services to people with disabilities

to communicate effectively with us, such as:qualified sign language interpreters, and writteninformation in other formats (large print, audio,accessible electronic formats, other formats),

• Free language services to people whoseprimary language is not English, such as:qualified interpreters and information written inother languages.

You can also file a civil rights complaint with the U.S.Department of Health and Human Services, Office forCivil Rights electronically through the Office for CivilRights Complaint Portal, available athttps://ocrportal.hhs.qov/ocr/portal/lobby.jsf or by mailor phone at: U.S. Department of Health and HumanServices, 200 Independence Avenue SW., Room509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms areavailable athttp://www .hhs.qov/ocr/office/file/index. html .

YO041 HM 17 47643 Accepted 10/14/2016 Taglines as of 10/14/2016