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Christian Brothers Employee Benefit Trust Plan Option: MP 5127 – RX 1300Summary of Benefits and Coverage: What this Plan Covers & What it CostsSBC 127 5 1300 20150414Plan Year 1/1-12/31 Coverage Period: 7/1/15-12/31/15Coverage for: Individual Family Plan Type: PPOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document atwww.myCBS.org/health or by calling 1-800-807-0400.Important QuestionsAnswersWhat is the overalldeductible?In-Network 750 Individual / 2,250 FamilyOut-of-Network 1,000 Individual / 3,000 FamilyAre there other deductiblesfor specific services?No.Is there an out–of–pocketlimit on my expenses?Medical In-NetworkYes. 3,000 Individual / 6,000 FamilyMedical Out-of-NetworkYes. 6,000 Individual / 12,000 FamilyPrescription Out-of-PocketYes. 1,600 Individual / 3,200 FamilyWhy this Matters:You must pay all the costs up to the deductible amount before this plan beginsto pay for covered services you use. If a copayment is indicated the deductibledoes not apply. Your plan year is January 1 through December 31. Yourdeductible starts over each January 1. Any portion of the deductible met in thelast quarter of the previous plan year will carry over to the current plan year. Seethe chart starting on page 2 for how much you pay for covered services after youmeet the deductible. In-Network & Out-of-Network deductibles reduce eachother.For preventive services the In-Network deductible does not apply.You don’t have to meet deductibles for specific services, but see the chartstarting on page 2 for other costs for services this plan covers.The out-of-pocket limit is the most you could pay during a coverage period(usually one year) for your share of the cost of covered services. This limit helpsyou plan for health care expenses. Your medical deductible, copayments, andcoinsurance apply toward the medical out-of-pocket limit. In-Network & Outof-Network out-of-pocket limits reduce each other.Your prescription copayments apply toward the prescription out-of-pocketlimit.What is not included in theout–of–pocket limit?Premiums, balance-billed charges, penalty fornon-notification of hospital admission and otherservices requiring pre-certification, and healthcare this plan does not cover.Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.Is there an overall annuallimit on what the plan pays?No, this policy has no overall annual limit on theamount it will pay each year.The chart starting on page 2 describes limits on specific covered services.Does this plan use anetwork of providers?Yes. Your network is Cigna. SeemyCBS.org/ppo-cigna for a list of medicalparticipating providers.If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Please note, your in-network doctoror hospital may use an out-of-network provider for some services. Plans use theQuestions: Call 1-800-807-0400 or visit us at www.myCBS.org/health or email at hbscustomerservice@cbservices.org. If you aren’t clear about any of theunderlined terms used in this form, see the Glossary. You can view the Glossary at www.myCBS.org/health or call 1-800-807-0400 to request a copy.Page 1 of 8

Christian Brothers Employee Benefit Trust Plan Option: MP 5127 – RX 1300Summary of Benefits and Coverage: What this Plan Covers & What it CostsSBC 127 5 1300 20150414Plan Year 1/1-12/31 Coverage Period: 7/1/15-12/31/15Coverage for: Individual Family Plan Type: PPOterm in-network, preferred, or participating for providers in their network. Seethe chart starting on page 2 for how this plan pays different kinds of providers.Do I need a referral to see aspecialist?No. You don’t need a referral to see aspecialist.You can see the specialist you choose without permission from this plan.Are there services this plandoesn’t cover?Yes.Some of the services this plan doesn’t cover are listed on page 5. See yourpolicy or plan document for additional information about excluded services. Copayments are fixed dollar amounts (for example, 15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’sallowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change if you haven’t met yourdeductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay and the allowed amountis 1,000, you may have to pay the 500 difference. (This is called balance billing.) This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts.CommonMedical EventIf you visit a health careprovider’s office orclinicServices You May NeedYour Cost If You Use anIn-Network ProviderOut-of-Network ProviderPrimary care visit to treat aninjury or illness 25 Copayment / visit40% Coinsurance / visitSpecialist visit 50 Copayment / visit40% Coinsurance / visitOther practitioner office visit20% Coinsurance / visit40% Coinsurance / visitNo ChargePrimary Care - 40%CoinsuranceFree Standing Clinic –40% CoinsurancePreventive care / screening /immunizationLimitations & ExceptionsNone.In-Network Allergy injections 5Copayment / visit.Limited to 12 visits per year, combined forall providers including, but not limited toacupuncturists & massage therapists.Health Care Reform guidelines apply. Outof-Network Payment may differ based onplace of service.Questions: Call 1-800-807-0400 or visit us at www.myCBS.org/health or email at hbscustomerservice@cbservices.org. If you aren’t clear about any of theunderlined terms used in this form, see the Glossary. You can view the Glossary at www.myCBS.org/health or call 1-800-807-0400 to request a copy.Page 2 of 8

Christian Brothers Employee Benefit Trust Plan Option: MP 5127 – RX 1300Summary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventServices You May NeedSBC 127 5 1300 20150414Plan Year 1/1-12/31 Coverage Period: 7/1/15-12/31/15Coverage for: Individual Family Plan Type: PPOYour Cost If You Use anIn-Network ProviderOut-of-Network ProviderDiagnostic test (x-ray, bloodwork)Lab Work – No ChargeRadiology – 20%Coinsurance40% CoinsuranceImaging (CT/PET scans, MRIs)20% Coinsurance40% CoinsuranceIf you have a testIf you need drugs totreat your illness orconditionTo find more informationabout prescription drugcoverage or to locate anetwork pharmacy log intowww.myCBS.org/healthand click on MyPrescription Drugs or callExpress Scripts at800-718-6601.If you have outpatientsurgeryIf you need immediatemedical attentionGeneric drugsPreferred drugsNon-Preferred drugsSpecialty drugsFacility fee (e.g., ambulatorysurgery center)Physician/surgeon feesEmergency room servicesEmergency medicaltransportation 10 / prescription (retail); 25 / prescription (mailorder) 35 / prescription (retail); 90 / prescription (mailorder) 60 / prescription (retail); 150 / prescription (mailorder)Deductible waived for Lab Work. Limitedto services performed outside physician’soffice. Payment may differ based on placeof service.Limited to services performed outsidephysician’s office. Payment may differbased on place of service. Precertificationis required. A 25% penalty up to 300 mayapply.Same as In-Network 20% coinsurance penaltyCovers up to 30-day supply retailprescription; 90-day supply mail orderprescription.Same as In-Network 20% coinsurance penaltyRetail purchases for maintenanceprescriptions are limited to an initial fill andtwo subsequent refills. Members whocontinue to use retail will pay the maildelivery copayment, however, only up to a30-day supply will be dispensed.Same as In-Network 20% coinsurance penaltyAs categorized above20% CoinsuranceLimitations & Exceptions40% CoinsuranceSee your policy or plan document foradditional information.None.20% Coinsurance40% Coinsurance20% Coinsurance after 100 CopaymentNone.Copayment is waived if admitted.20% CoinsuranceNone.Questions: Call 1-800-807-0400 or visit us at www.myCBS.org/health or email at hbscustomerservice@cbservices.org. If you aren’t clear about any of theunderlined terms used in this form, see the Glossary. You can view the Glossary at www.myCBS.org/health or call 1-800-807-0400 to request a copy.Page 3 of 8

Christian Brothers Employee Benefit Trust Plan Option: MP 5127 – RX 1300Summary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventServices You May NeedIf you are pregnantCoverage for: Individual Family Plan Type: PPOYour Cost If You Use anOut-of-Network ProviderPrimary Care – 40%CoinsuranceFree Standing Clinic –40% CoinsuranceEmergency Room – 20%Coinsurance after 100CopaymentFacility fee (e.g., hospital room)20% Coinsurance40% CoinsurancePhysician/surgeon fee20% CoinsuranceSpecialist – 50Copayment / visitOutpatient Facility –20% Coinsurance40% CoinsuranceSpecialist – 40%Coinsurance / visitOutpatient Facility – 40%Coinsurance20% Coinsurance40% CoinsuranceSpecialist – 50Copayment / visitOutpatient Facility –20% CoinsuranceSpecialist – 40%Coinsurance / visitOutpatient Facility – 40%Coinsurance20% Coinsurance40% Coinsurance 25 Copayment / visit40% Coinsurance20% Coinsurance40% CoinsuranceMental/Behavioral healthoutpatient servicesIf you have mentalhealth, behavioralhealth, or substanceabuse needsPlan Year 1/1-12/31 Coverage Period: 7/1/15-12/31/15In-Network ProviderPrimary Care – 25CopaymentFree Standing Clinic –20% CoinsuranceEmergency Room – 20%Coinsurance after 100CopaymentUrgent careIf you have a hospitalstaySBC 127 5 1300 20150414Mental/Behavioral healthinpatient servicesSubstance use disorderoutpatient servicesSubstance use disorderinpatient servicesRoutine prenatal and postnatalcareDelivery and all inpatientservicesLimitations & ExceptionsPayment may differ based on place ofservice. This applies to emergency roomor urgent care services.Precertification is required. A 25% penaltyup to 2,000 may apply.None.Payment may differ based on place ofservice.Precertification is required. A 25% penaltyup to 2,000 may apply.Payment may differ based on place ofservice.Precertification is required. A 25% penaltyup to 2,000 may apply.Copayment applies to initial prenatal visitonly (per pregnancy).None.Questions: Call 1-800-807-0400 or visit us at www.myCBS.org/health or email at hbscustomerservice@cbservices.org. If you aren’t clear about any of theunderlined terms used in this form, see the Glossary. You can view the Glossary at www.myCBS.org/health or call 1-800-807-0400 to request a copy.Page 4 of 8