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WISCONSIN EHB BENCHMARK PLANSUMMARY INFORMATIONPlan TypePlan from largest small group product, Point of ServiceIssuer NameUnitedHealthcare Insurance CompanyProduct NameChoice PlusPlan NameChoice Plus Definity HSA Plan A92NSSupplemented Categories(Supplementary Plan Type) Habilitative ServicesIncluded Benchmark(Yes/No)NoPediatric Oral (FEDVIP)Pediatric Vision (FEDVIP)Habilitative Services Definedby StateNo(Yes/No)Wisconsin—1

BENEFITS AND LIMITSBenefit InformationBCEHB Benefit Description(may be the same asthe Benefit name)Primary Care Visit Yes Primary are Visit toto Treat an InjuryTreat an Injury oror IllnessIllnessSpecialist VisitYes Specialist VisitOtherYes Dentist, Podiatrist,Practitionerclinical social worker,Office Visitmarriage and family(Nurse, Physiciantherapist, utpatientYes Outpatient Facility Facility Fee (e.g.,SurgeryAmbulatorySurgery Center)OutpatientYes OP ervicesl ServicesHospice Services Yes Hospice CareNon-EmergencyCare WhenTraveling Outsidethe U.S.Routine DentalServices (Adult)InfertilityTreatmentLong-Term/Custodial NursingHome CarePrivate-DutyNursingRoutine Eye ExamRoutine Vision(Adult)ExaminationsABenefitUrgent CareCenters orFacilitiesHome HealthCare ServicesEmergency Is theQuantitative LimitLimit Unit MinimumBenefitLimit eredNoJExplanationsBenefits include allergy injections.Benefits include allergy injections.KAdditionalLimitations redNoNoCoveredNoNot CoveredNoNoNoNot CoveredNot CoveredThis exclusion does not apply to services required totreat or correct underlying causes of infertility.Not CoveredNot CoveredCoveredYesYesUrgent Care CenterServicesCoveredNoYesHome Health CareCoveredYesYesEmergency HealthCoveredServices - OutpatientER AmbulanceCoveredService - (air/ground)NoYesGeneral InformationIExclusionsNo160Exam every 2yearsVisits per yearBenefits are not available for charges connected tothe purchase or fitting of eyeglasses or contactlenses.NoNoOne visit equals up to four hours of skilled careservices.NoNoNoWisconsin—2

Benefit InformationBCEHB Benefit Description(may be the same asthe Benefit name)InpatientYes IP Hospital ServicesHospital Services(e.g., HospitalStay)InpatientYes Physician Fees forPhysician andSurgical and MedicalSurgical ServicesServicesBariatric SurgeryCosmetic SurgerySkilled Nursing Yes Skilled NursingFacilityFacilityPrenatal andYes Pre/Post Natal andPostnatal CareDelivery - PhysicianDelivery and All Yes Inpatient HospitalInpatient ServicesServicesfor MaternityCareMental/Behavior Yes Mental Healthal HealthServicesOutpatientServicesMental/Behavior Yes Mental Healthal HealthServicesInpatient ServicesSubstance Abuse Yes Substance UseDisorderDisorder ServicesOutpatientServicesSubstance Abuse Yes Substance UseDisorderDisorder ServicesInpatient ServicesGeneric DrugsYes GenericPreferred Brand Yes Preferred BrandDrugsNon-PreferredYes Non-Preferred BrandBrand DrugsSpecialty Drugs Yes SpecialtyOutpatientYes PT, OT, itationYes Habilitation ServicesServicesChiropractic Care Yes ManipulativeTreatmentABenefitDEFGHIs theQuantitative LimitLimit Unit MinimumBenefitLimit eredNoCoveredGeneral InformationIExclusionsJExplanationsNoNot CoveredNot CoveredCoveredYesKAdditionalLimitations orRestrictions?NoNo30Days per sits per year20 visits for each type of therapy.NoYesWisconsin—3

Benefit InformationGeneral InformationBCDEFGHIEHB Benefit DescriptionIs theQuantitative LimitLimit Unit MinimumExclusions(may be the same as BenefitLimit onQuantityand/orStaythe Benefit name) Covered?Service?DescriptionDurable Medical Yes Durable MedicalCoveredYes1Item per 3Prescribed or non-prescribed medical supplies andEquipmentEquipmentyears, up todisposable supplies. Examples include: Compression2500 dollarsstockings, Ace bandages, Gauze and dressings,per year forUrinary catheters, Tubings and masks unlessnon-essentialnecessary for the effective use of covered DME;DMEDevices used specifically as safety items or to affectperformance in sports-related activities; Bloodpressure cuff/monitor, Enuresis alarm, Non-wearableexternal defibrillator, Trusses, Ultrasonic nebulizers;Devices and computers to assist in communicationand speech except for speech aid devices andtracheo-esophageal voice devices covered underDME; Oral appliances for snoring; Any device,appliance, pump, machine, stimulator, or monitorthat is fully implanted into the body;Repairs/Replacement due to misuse, maliciousdamage or gross neglect or to replace lost or stolenitemsABenefitHearing AidsYesDiagnostic Test(X-Ray and LabWork)Imaging(CT/PET Scans,MRIs)YesYesPreventive Care/ YesScreening/ImmunizationRoutine FootCareAcupunctureWeight LossProgramsRoutine Eye Exam Yesfor ChildrenEye Glasses for YesChildrenHearing Aids Covered Personsover age 18Lab, X-Ray andDiagnostics OutpatientLab, X-Ray and MajorDiagnostics - CT, PET,MRI, MRA andNuclear Medicine OutpatientPreventive Servicesas defined by HealthCare Reform2500Dollars peryearBone Anchored Hearing Aids unless certain criteriaexists.JExplanationsKAdditionalLimitations orRestrictions?YesIncludes cochlear implants. Examples of DurableMedical Equipment include: Equipment to assistmobility, such as a standard wheelchair; A standardHospital-type bed; Oxygen and the rental ofequipment to administer oxygen (including tubing,connectors and masks); Delivery pumps for tubefeedings (including tubing and connectors); Braces,including necessary adjustments to shoes toaccommodate braces. Braces that stabilize an injuredbody part and braces to treat curvature of the spineare considered Durable Medical Equipment and are aCovered Health Service. Braces that straighten orchange the shape of a body part are orthotic devices,and are excluded from coverage. Dental braces arealso excluded from coverage; Mechanical equipmentnecessary for the treatment of chronic or acuterespiratory failure (except that air-conditioners,humidifiers, dehumidifiers, air purifiers and filters,and personal comfort items are excluded fromcoverage); Burn garments; Insulin pumps and allrelated necessary supplies as described underDiabetes Services; External cochlear devices andsystems. Benefits for cochlear implantation areprovided under the applicable medical/surgicalBenefit categories in this Certificate.Limits do not apply to enrolled dependent children. YesCoveredYesCoveredNoNoCoveredNoNoCoveredNoNoNot CoveredNot CoveredNot CoveredRoutine eye examCoveredYes1Visit per yearNoEye Glasses forChildrenCoveredYes1Pair of glasses(lenses andframes) peryearNoWisconsin—4

Benefit InformationBCDEEHB Benefit DescriptionIs theQuantitative(may be the same as BenefitLimit onthe Benefit name) Covered?Service?Dental Check-Up Yes Dental ExamsCoveredYesfor ChildrenRehabilitativeYes Rehabilitative Speech CoveredYesSpeech TherapyTherapyRehabilitativeYes RehabilitativeCoveredYesOccupational andOccupational andRehabilitativeRehabilitativePhysical TherapyPhysical TherapyWell Baby VisitsNot Coveredand CareLaboratoryYes LaboratoryCoveredNoOutpatient andOutpatient andProfessionalProfessional ServicesServicesX-rays andYes X-rays and Diagnostic CoveredNoDiagnosticImagingImagingBasic Dental Care Yes Basic Dental Care - CoveredNo- ChildChildOrthodontia Yes Orthodontia - Child CoveredNoChildMajor DentalYes Major Dental Care - CoveredNoCare - ChildChildBasic Dental CareNot Covered- AdultOrthodontia Not CoveredAdultMajor DentalNot CoveredCare – AdultAbortion forNot CoveredWhich PublicFunding isProhibitedTransplantYes TransplantCoveredYesABenefitAccidental Dental YesAccidental DentalCoveredDialysisAllergy alysisYesDiabetes EducationCoveredNoNot CoveredNot CoveredNot CoveredCoveredNoYesFLimitQuantity20GHLimit Unit Minimumand/orStayDescriptionVisit every 6monthsVisits per year40Visits per year1General InformationIExclusionsJExplanationsLimitations, including dollar limits, may apply, seeEHB benchmark plan documents.KAdditionalLimitations orRestrictions?NoNoNoNoNoLimitations, including dollar limits, may apply, seeEHB benchmark plan documents.Limitations, including dollar limits, may apply, seeEHB benchmark plan documents.Limitations, including dollar limits, may apply, seeEHB benchmark plan documents.300003000Dollars pertransplant(OON only)Dollars peryearNoNoNoNoYesNoNoWisconsin—5

Benefit InformationGeneral InformationBCDEFGHIEHB Benefit DescriptionIs theQuantitative LimitLimit Unit MinimumExclusions(may be the same as BenefitLimit onQuantityand/orStaythe Benefit name) Covered?Service?DescriptionProstheticYes Prosthetic DevicesCoveredYes2500Dollars perOrthotic appliances that straighten or re-shape aDevicesyearbody part. Examples include foot orthotics and sometypes of braces, including over-the-counter orthoticbraces; Cranial banding; Repairs/Replacement due tomisuse, malicious damage or gross neglect or toreplace lost or stolen items.Infusion TherapyNot CoveredTreatment forYes Treatment forCoveredYes1250Dollars perTemporomandibTemporomandibularyear fordiagnosticular JointJoint DisordersproceduresDisordersand nonsurgicaltreatmentNutritionalNot CoveredCounselingReconstructive Yes ReconstructiveCoveredNoSurgerySurgeryClinical TrialsYes Clinical TrialsCoveredNoDiabetes CareYes Diabetes CareCoveredNoManagementManagementDentalYes Dental AnesthesiaCoveredNoAnesthesiaMental HealthYes Mental Health Other CoveredNoOtherPrescriptionYes Prescription DrugsCoveredNoDrugs OtherOtherNewbornYes Newborn ServicesCoveredNoServices ons orRestrictions?YesNoNoNoNoNoNoNoNoWisconsin—6

OTHER BENEFITSBenefit InformationGeneral InformationBCDEFGHIEHB Benefit DescriptionIs theQuantitative LimitLimit Unit MinimumExclusions(may be the same as BenefitLimit onQuantityand/orStaythe Benefit name) Covered?Service?DescriptionInpatient Rehab Yes Inpatient RehabCoveredYes60Days per yearOutpatientYes STCoveredYes20Visits per yearBenefits for speech therapy for the treatment ofRehabilitationdisorders of speech, language, voice, communicationand auditory processing only when the disorderServicesresults from Injury, stroke, cancer, CongenitalAnomaly, or Autism Spectrum Disorders.OutpatientYes cardiac rehabilitation CoveredYes36Visits per yearRehabilitationServicesOutpatientYes post-cochlearCoveredYes30Visits per yearRehabilitationimplant aural therapyServicesHearing AidsYes Hearing Aids CoveredYes1PurchaseCovered Persons(includingrepair andoverreplacement)age 18every threeyearsHearing AidsYes Hearing Aids –CoveredYes1Hearing aidEnrolled Dependentper ear, everychildren under agethree years18Hearing AidsYes Bone AnchoredCoveredYes1BoneHearing Aidsanchoredhearing aidper lifetimeABenefitCongenital Heart YesDisease SurgeryCongenital HeartDisease SurgeryCoveredYes30000Dental Services - YesAccident OnlyOstomy Supplies YesDental Services Accident OnlyOstomy esProsthetic DevicesCoveredYes1YesDollars persurgery (OONonly)Dollars pertoothDollars peryearPurchase of atype ofprostheticdevice everythree yearsJExplanationsKAdditionalLimitations orRestrictions?NoNoNoNoNoNoBone anchored hearing aids are excluded exceptNowhen either of the following applies: For CoveredPersons with craniofacial anomalies whose abnormalor absent ear canals preclude the use of a wearablehearing aid; For Covered Persons with hearing loss ofsufficient severity that it would not be adequatelyremedied by a wearable hearing aid; Repairs and/orreplacement for a bone anchored hearing aid forCovered Persons who meet the above coveragecriteria, other than for malfunctions.NoNoNoNoWisconsin—7