Benefits Summaries And Plan Comparisons

Type of Service ActiveCare 3   General Provisions Network Non-Network No primary care physician required Deductible (per plan year)   Individual - You Pay None $500 Family - You Pay None $1,500 Out-of-pocket maximum (per plan year)   Individual - You pay $1,000 plus copays $3,000 plus deductible and copays Family - You pay N/A N/A Maximum Lifetime Benefit Unlimited $1,000,000 Doctor and Lab Services Doctor office visits - You pay $20 copay for primary $30 copay for specialist 40% after deductible Allergy injections - You Pay 20% (when no office visit is billed) 40% after deductible Office surgery - You Pay 20% 40% after deductible Outpatient surgery - You Pay 20% 40% after deductible Maternity care (doctor charges only; see Hospital/Facility Services for inpatient charges) - You Pay $20 copay for primary $30 copay for specialist (for initial visit only; 20% for delivery) 40% after deductible Inpatient doctor visits - You Pay 20% 40% after deductible Contraceptive devices - You Pay 20% 40% after deductible Preventive Care Doctor office visits $20 copay for primary $30 copay for specialist (includes all preventive care services billed with an office visit by a network doctor) Services limited to one per person per plan year: routine physicals, OB/GYN well-woman exams, routine mammograms, and eye exams. Other services include well-baby exams, immunizations, hearing exams, and PSA, colorectal cancer, osteoporosis screenings 40% after deductible Services limited to one per person per plan year: routine physicals, OB/GYN well-woman exams, routine mammograms, and eye exams. Hospital/Facility Services Inpatient hospital and other inpatient charges - You Pay 20% plus $100 copay per day ($500 maximum copay per admission; $1500 maximum copay per plan year; preauthorization required) 40% plus $100 copay per day ($500 maximum copay per admission; $1500 maximum copay per plan year; preauthorization required) Outpatient surgery - You Pay 20% plus $100 copay per visit 40% plus $100 copay per visit Outpatient hospital/facilities - You Pay 20% 40% after deductible Emergency room care - You Pay 20% after $100 copay (copay waived if admitted) Behavioral Health (Mental Health and Chemical Dependency) Mental Health Preauthorization required Inpatient facility - You Pay 20% plus $100 copay per day ($500 maximum copay per admission; $1500 maximum copay per plan year; preauthorization required) 40% plus $100 copay per day ($500 maximum copay per admission; $1500 maximum copay per plan year; preauthorization required) Maximum per plan year 30 days Inpatient physician charges - You pay 20% 40% after deductible Maximum per plan year 30 visits Outpatient/Office visit 20% 40% after deductible (maximum $60 allowable per visit) Maximum per plan year 30 visits Chemical dependency Maximum of two separate series per lifetime Inpatient facility - You pay 20% plus $100 copay per day ($500 maximum copay per admission; $1500 maximum copay per plan year; preauthorization required) 40% plus $100 copay per day ($500 maximum copay per admission; $1500 maximum copay per plan year; preauthorization required) Inpatient physician charges - You pay 20% 40% after deductible Outpatient - You pay 20% 40% after deductible Office visits - You pay $20 copay for primary $30 copay for specialist 40% after deductible Serious Mental Illness   Preauthorization required Inpatient facility - You Pay 20% plus $100 copay per day ($500 maximum copay per admission; $1500 maximum copay per plan year; preauthorization required) 40% plus $100 copay per day ($500 maximum copay per admission; $1500 maximum copay per plan year; preauthorization required) Maximum per plan year No day limitations Inpatient physician charges - You pay 20% 40% after deductible Maximum per plan year No visit limitations Outpatient/Office visit - You pay $20 copay for primary $30 copay for specialist (20% for other services) 40% after deductible Maximum per plan year No visit limitations Prescription Drugs Drug deductible (per person, per plan year) $50 Retail Short-Term Up to 30-day supply Up to 30-day supply Generic - You pay Preferred - You pay Non-preferred Brand - You pay $10 copay $25 copay* $40 copay* You will be reimbursed the amount that would have been charged by a network pharmacy less the required copay Retail Maintenance (after second fill) Up to 30-day supply Up to 30-day supply Generic - You pay Preferred - You pay Non-preferred Brand - You pay $15 copay $35 copay* $55 copay* You will be reimbursed the amount that would have been charged by a network pharmacy less the required copay Medco by Mail Up to 90-day supply N/A Generic - You Pay Preferred Brand - You pay Non-preferred Brand - You pay $20 copay $62.50 copay* $100 copay* N/A Maximum Plan Year Prescription Benefit Unlimited

*

If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. This is a general summary of your TRS-ActiveCare plan options. Please refer to your Benefits Booklet/Evidence of Coverage for details specific to your plan. Please see the Limitations and Exclusions section at the back of your enrollment guide.