inKind Open Enrollment

2022 OPEN ENROLLMENT EFFECTIVE FEBRUARY 1, 2022

INSURANCE CARRIER UNITED HEALTHCARE Gold Choice Plus CEFZ PPO Plan Name Rx K35Y Network Full Network Non PPO PPO Base Plan: (Neg Fee) Calendar Year Deductible Individual $3,500 $5,000 Gold Choice Family $7,000 $15,000 Out-of-Pocket Limit Individual $8,500 $10,000 Plus CEFZ Family $17,000 $30,000 Coinsurance 80% 50% Lifetime Maximum Unlimited PPO Plan Desg. $15 / $50 Office Visits 50% PPO $15 / $100 Diagnostic Test (Lab/X-Ray) Office 80% 50% Adv Imaging (MRI/PET/CT) Hospital 80% 50% Hospitalization Inpatient Services 80% 50% ER Services (waived if admitted) $300 Copay, 80% Chiropractic Care $15 Copay 50% 35 visits per year Durable Medical Equipment (DME) 80% 50% Rx Ded: N/A Prescription Drugs $10 Tier 1 / $40 Tier 2 / (In-Network Only; please refer to full summary for Out of $125 Tier 3 Network coverage) Tier 4: $300

INSURANCE CARRIER UNITED HEALTHCARE Silver Choice Plus CEFC PPO Plan Name Rx K35Y Network Full Network Non PPO PPO (Neg Fee) Silver Choice Calendar Year Deductible Individual $6,500 $10,000 Family $13,000 $30,000 Plus CEFC Out-of-Pocket Limit Individual $8,500 $20,000 Family $17,000 $60,000 PPO Plan Coinsurance 80% 50% Lifetime Maximum Unlimited Desg. $15 / $50 Office Visits 50% PPO $15 / $100 Diagnostic Test (Lab/X-Ray) Office 80% 50% Adv Imaging (MRI/PET/CT) Hospital 80% 50% Hospitalization Inpatient Services 80% 50% ER Services (waived if admitted) $300 Copay, 80% Chiropractic Care $15 Copay 50% 35 visits per year Durable Medical Equipment (DME) 80% 50% Rx Ded: N/A Prescription Drugs $10 Tier 1 / $40 Tier 2 / (In-Network Only; please refer to full summary for Out $125 Tier 3 of Network coverage) Tier 4: $300

INSURANCE CARRIER UNITED HEALTHCARE Silver Choice Plus CECY PPO Plan Name Rx K35Y - HSA Network Full Network Non PPO PPO (Neg Fee) Calendar Year Deductible Silver Choice Individual $5,000 $10,000 Family $10,000 $30,000 Out-of-Pocket Limit Plus CECY Individual $6,000 $20,000 Family $12,000 $60,000 PPO Plan Coinsurance 100% 70% Lifetime Maximum Unlimited Desg. Office Visits 100% 70% PPO Diagnostic Test (Lab/X-Ray) Office 100% 70% Adv Imaging (MRI/PET/CT) Hospital 100% 70% Hospitalization Inpatient Services 100% 70% ER Services (waived if admitted) 100% Chiropractic Care 100% 70% 35 visits per year Durable Medical Equipment (DME) 100% 70% After Medical Deductible is Met Prescription Drugs $10 Tier 1 / $40 Tier 2 / (In-Network Only; please refer to full summary for Out of $125 Tier 3 Network coverage) Tier 4: $300

INSURANCE CARRIER UNITED HEALTHCARE Platinum Choice Plus CODX PPO Plan Name Rx K35Y Network Full Network Non PPO PPO (Neg Fee) Calendar Year Deductible Platinum Choice Individual $1,000 $5,000 Family $2,000 $15,000 Out-of-Pocket Limit Plus CODX Individual $2,400 $10,000 Family $4,800 $30,000 Coinsurance 80% 50% PPO Plan Lifetime Maximum Unlimited Desg. $10 / $40 Office Visits 50% PPO $10 / $80 Diagnostic Test (Lab/X-Ray) Office $40 Copay 50% Adv Imaging (MRI/PET/CT) Hospital $500 Copay 50% Hospitalization Inpatient Services 80% 50% ER Services (waived if admitted) $300 Copay, 80% Chiropractic Care $10 Copay 50% 35 visits per year Durable Medical Equipment (DME) 80% 50% Rx Ded: N/A Prescription Drugs $10 Tier 1 / $40 Tier 2 / (In-Network Only; please refer to full summary for Out of $125 Tier 3 Network coverage) Tier 4: $300

INSURANCE CARRIER UNITED HEALTHCARE Gold Nexus ACO CEOO HMO Plan Name Rx K35Y Network Nexus HMO Network Calendar Year Deductible Individual $2,000 Gold Nexus Family $4,000 Out-of-Pocket Limit Individual $8,500 ACO CEOO Family $17,000 Office Visit Copay - Designated Network $30 PCP / $60 Spec HMO Plan Office Visit Copay - Non Desginated $60 PCP / $120 Spec Diagnostic Test (Lab/X-Ray) No Copay after ded Adv Imaging (MRI/PET/CT) No Copay after ded Hospitalization Inpatient Services $500 Copay, 80% after ded Outpatient Surgery $250 Copay, 80% after ded Urgent Care $50 Copay ER Copay (waived if admitted) $300 Copay after ded Chiropractic Care $60 Copay 35 visits per calendar year Durable Medical Equipment (DME) No Copay after ded Rx Ded: N/A $10 Tier 1 / $40 Tier 2 / Prescription Drugs $125 Tier 3 Tier 4: $300

INSURANCE CARRIER UNITED HEALTHCARE Plan Name Voluntary Vision Network UHC Vision Network Voluntary Exam Copay $10 Material Copay $25 Vision Frequency Schedule Examination 12 Months Lenses 12 Months Frames 12 Months Benefit Allowance Schedule Preferred Out-of-Network Subject to applicable copays Providers Reimbursement Examination Covered in Full $40 Single Vision Lenses Covered in Full $40 Bifocal Lenses Covered in Full $60 Trifocal Lenses Covered in Full $80 Contact Lenses Allowance - Necessary Covered in Full $210 Contact Lenses Allowance - Elective $125 $100 Frames $130 $45

INSURANCE CARRIER DELTA DENTAL Advantage 200 PPO Plus Premier 2500 Plan Name w/ D&P Ortho 1500 Major Services Waiting Period None Advantage PPO Non PPO Basis of Reimbursement 90th $50 $50 200 PPO Plus Annual Deductible Calendar Year Calendar Year/Policy Year Yes Waived for Preventive Premier 2500 Preventive: Oral Exams, Cleanings, Bitewing X-Rays, & Other 100% 100% Procedures Basic: Lab Test, Fillings, General Anesthesia & Other 80% 80% Procedures Major: Crowns, Bridges, Dentures, 50% 50% & Other Procedures Oral Surgery Basic Endodontics & Periodontics Basic Implants Major Fillings - Posterior Teeth (Molars) Amalgam Crowns Frequency Limitation 1 per 5 years Annual Benefit Maximum $2,500 Orthodontia Not Covered