Independence @1

Medical Benefit HighlightsPersonal Choice HDHP HDl-HCI Haverford College

Covered Services

Benefits per Calendar YearDeductible (Aggregate)1

Individual/Family

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

Coinsurance

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

$1 ,500/$3,000 $5,000/$10.000

$6 ,350/$ 12,700

0%

$10,000/$20,00050%

Preventive ServicesPreventive Care

Preventive ColonoscopyPreventive Plus Providers

Hospital Based

In-Network

No charge no deductibleOut-of-Work50% no deductible

No charge no deductibleNo charge no deductible

Not covered50% no deductible

Physician ServicesPrimary Care Physician (PCP) Office Visit

Specialist Office VisitRetail Health Clinic Visit

Urgent Care Visit

In-Network

No charge after deductibleNo charge after deductibleNo charge after deductibleNo charge after deductible

Out-of-Network50% after deductible

50% after deductible

50% after deductible50% after deductible

Virtual Care3Telemedicine

TeledermatologyTelebehavioral Health

In-Network

No charge after deductibleNo charge after deductibleNo charge after 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)5

In-Network Out-of-Network

No charge after deductible

No charge after deductible

50% after deductible

50% after deductible

No charge after deductibleNo charge after deductibleNo charge after deductible

50% after deductible

50% after deductible50% after deductible

Emergency ServicesEmergency Room

Emergency Ambulance

Non-Emergency Ambulance

In-Network

No charge after deductibleNo charge after deductibleNo charge after deductible

Out-of-NetworkCovered at In-Network level

Covered at In-Network level50% after deductible

Reference ID: 1004082301012021

Independence @I

Hospital ServicesInpatient Hospital Services (In-Network:365 days/year; Out-of-Network: 70 days/year)6Observation Services

Maternity Hospital Services6Inpatient ProfessIonal Services (includesMaternity)

In-Network

No charge after deductible

Out-of-Network50% after deductible

No charge after deductibleNo charge after deductibleNo charge after deductible

50% after deductible

50% after deductible

50% after deductible

Outpatient SurgeryFreestanding

Hospital BasedOutpatient Professional Services

In-Network

No charge after deductibleNo charge after deductibleNo charge after deductible

Out-of-Network50% after deductible

50% after deductible

50% after deductible

Outpatient DiagnosticsDiagnostic Medical (EKG)Routine Radiotogy (X-Ray)

Freestanding

Hospital Based

Advanced Imaging (MRI/MRA,CT/CTAScan, PET Scan)

Freestanding

Hospital Based

In-Network

No charge after deductible

Out-of-Network50% after deductible

No charge after deductibleNo charge after deductible

50% after deductible

50% after deductible

No charge after deductibleNo charge after deductible

50% after deductible

50% after deductible

Outpatient Lab and PathologyFreestanding

Hospital Based

In-Network

No charge after deductibleNo charge after deductible

Out-of-Network50% after deductible

50% after deductible

Other Medical Services

Spinal Manipulations (20 visits/year)5Acupuncture (18 visits/year)5

Standard InjectablesAllergy InjectionsBiotech/Specialty Injectables

Home/Office

OutpatientChemotherapy

Dialysis

Skilled Nursing Facility (120 days/year)5Home Health

Hospice

Durable Medical Equipment (DME)

In-Network

No charge after deductibleNo charge after deductible

No charge after deductible

No charge after deductible

Out-of-Network50% after deductible50% after deductible50% after deductible50% after deductible

No charge after deductibleNo charge after deductibleNo charge after deductibleNo charge after deductibleNo charge after deductibleNo charge after deductibleNo charge after deductibleNo charge 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

Reference ID: 1004082301012021

Independence @I

Mental Health – Outpatient (includesserious mental illness and substanceabuse)

Mental Health - Inpatient (includesserious mental illness and substanceabuse)6

No charge after deductible 50% after deductible

No charge after deductible 50% after deductible

1

2

3

4

5

6

Aggregate deductible: For family coverage, the entire family deductible must be met before copayments or coinsurance are applied for anindividual member.

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

Combined 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

The Personal Choice(B) Preferred Provider Organization (PPO) gives you freedom of choice by allowing you to select your own doctors and hospitalsYou 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 Blue(_,ard® 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 resultthis 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: 71 1 )

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: 1004082301012021

Independence @I

Drug Benefit HighlightsPersonal Choice HDHP HDl-HCI Haverford College Rx

Covered Services

Benefits per Calendar YearDeductible

Individual/FamilyOut-of-Pocket Maximum

Individual/Family

Formulary

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

Medical deductible applies. Medical deductible applies.

Combined with Medical Combined with Medical

Select

Retail PharmacyTier 1 Generic Drugs

In-Network$5 after deductible

Out-of-Network50% Reimbursement afterdeductible

50% Reimbursement afterdeductible

50% Reimbursement afterdeductible

30 day supply max

Tier 2 Preferred Brand $20 after deductible

Tier 3 Non-Preferred Drugs $45 after deductible

Dispensing Limits 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

$10 after deductible

$40 after deductible

$90 after deductible

90 day supply max

Not coveredNot coveredNot coveredNot covered

Drug CoverageACA Preventive Drugs2Compound Medications

Contraceptives

Diabetic Supplies (i.e., test strips)

Glucometers (no copaymenUcoinsurance requiredat participating pharmacies after deductible)Insulin

Insulin Needles and Syringes

Lancets (no copayment/coinsurance required atparticipating pharmacies after deductible)

Prescribed Tobacco Cessation Drugs (RX and OTC)

Retin-A (up to Age 35)

Allergy SerumI

Blood, Blood Plasma

r

In-NetworkCovered

Covered

Covered

Covered

Covered

Out-of-NetworkCovered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

Covered

CoveredCovered

Not coveredNot coveredNot coveredNot covered

Covered

Covered

Not covered

Not covered

Not covered

Not covered

Reference ID: 1004082801012021

Independence @Immunization Agents Not covered Not covered

Injectable Fertility Drugs Not covered Not covered

Non-Federal Legend DrugsOver-The-Counter Drugs (Non-Prescription)

Not covered Not coveredNot covered

Not covered

Not coveredNot coveredWeight Control Drugs

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: 71 1),

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: 1004082801012021

Language Assistance Services Tagalog: PAUNAWA: Kung nagsasalita ka ngTagalog, magagamit mo ang mga serbisyo na tulongsa wika nang walang bayad. Tumawag sa1 -800-275-2583.

Spanish: ATENCION: Si habla espa6ol, cuenta consewicios de asistencia en idiomas disponiblesde forma gratuita para usted. Llarne al1-800-275-2583 (TTY: 711). French: ATTENTION: Si vous parlez frangais, des

services d'aide linguistique-vous sont propos6sgratuitement. Appelez Ie 1-800-275-2583.Chinese: H&: luRe:if OII Jg:aLl+B$1j%©Aqiti=

tD.ELBE%. it IB 1-800-275-2583.Pennsylvania Dutch: BASS UFF: Wann duPennsylvania Deitsch schwetzscht, kannscht du Hilfgriege in dei eegni Schprooch unni as es dich ennicheppes koschte zellt. Ruf die Nummer 1-800-275-2583

Korean: gF LH Alg : Be CHS /\F gap /\lb gg , a CH

RIg Al EIIAS PSB OIg aPg + £££ LI EP .1-800-275-2583 W ge 8 aF abd Al 9 .

Portuguese: ATEN(,,Ao: se voc6 fala portugu6s,encontram-se disponiveis servigos gratuitos deassist6ncia ao idioma. Ligue para 1-800-275-2583.

Hindi: Hra &: dk Hn fMI gjad i at 3rn# fBuqqal+HrvraFma+3Tt wwt! fIgfm q:+1 -800-275-2583 1

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eUNL tl,}ta &cut;a ,ItU el qL: eVaa& B.German: ACHTUNG: Wenn Sie Deutsch sprechen,k6nnen Sie kostenlos sprachliche UnterstOtzunganfordern . wahlen Sie 1-800-275-2583.

1-800-275-2583 aa 88.

Vietnamese: LL/U Y: N6u bgn n6i ti6ng viet, chClng t6isd cung cap djch vy ha trq ng6n ngO mi6n phi chobgn. Hay gQi 1-800-275-2583.

Japanese: fH4 : Hmi#ii rl4i#m + Ii, gi97 S/ 79 yx't–E'x (M++) &:#IIMb~/If:'}} it.1-800-275-2583 Ab’En < tI $ b ~.

Russian: BHmMAHHE: Ecnu Bbl roBopuTe no-pyccKU,TO Mo>KeTe 6ecnnaTHO BOcnonb30BaTbcn ycnyraMU

nepeBona. Ten .: 1-800-275-2583.

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1-800-275-2583 .JU Ll .-JU u- ?-1) U ,gl j JKql J.+JiLl LWLd

Polish UWAGA: Je2eli m6wisz po polsku, mo2eszskorzysta6 z bezp+atnej pomocy jQzykowej . Zadzwohpod numer 1-800-275-2583. Navajo: Dif baa ak6 ninfzin: Dif saad bee y£nihi’go

Din6 Bizaad, saad bee £ka’anfda’iwo’dee’, t’ai jiik’eh.H6dfflnih koji’ 1-800-275-2583.Italian: ATTENZIONE: Se lei parla italiano, sono

disponibili sewizi di assistenza linguistica gratuitiChiamare il numero 1-800-275-2583. Urdu:

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French Creole: ATANSYON: Si w pale Krey61

Ayisyen, gen sdvis dd pou lang ki disponib gratis pouou. Rele 1-800-275-2583.

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Luhis IDeas Lin tom anus-igf yin Fm igf tFI :fist£iiGnm hn gains Gf$USd diFnnnHnFfn Etiama a n & a

8ni6 1 BlaiR tfltm8 1-800-275-25831CV U a

YO041 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.SDepartment of Health and Human Services, Office forCivil Rights electronically through the Office for CivilRights Complaint Portal, available athttps://ocrportal.hhs.qov/ocr/portal/lobbv,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 . h hs, gov/ocr/office/file/index, html .

YO041 HM 17 47643 Accepted 10/14/2016 Taglines as of 1 0/14/2016