Behavioral Health Professionals, Inc.

2016-2017 Benefit Summary

BLUE CARE NETWORK
Healthy Blue Living HMO / BLUE CROSS BLUE SHIELD PPO
Enhanced / Standard / In Network / Out-of-Network
Deductible-Individual / None / $1,000 / $100 / $250
Deductible-Family / None / $2,000 / $200 / $500
Office Calls Copay / $20 Primary/$20 Specialist / $20 Primary/$20 after Deductible Specialist / $20 / 70% after Deductible
Preventative Services / Covered 100% / Covered 100% / Covered 100% / Not Covered
Diagnostic Tests and X-Rays / Covered 100% / 70% after Deductible / 90% after Deductible / 70% after Deductible
Coinsurance Coverage after Deductible / 75% (only for inpatient hospital services and outpatient surgery) / 70% / 90% / 70%
True Out-of-Pocket Maximum-Individual / $6,350 / $3,000 / $600 / $1,750
True Out-of-Pocket Maximum-Family / $12,700 / $6,000 / $1,200 / $3,500
Urgent Care Copay / $35 / $35 / $20 / 70% after Deductible
Emergency Room Copay / $75 / $75 after Deductible / $100 / $100
Rx Drug Copay / $10 Generic/$40 Brand Name / $15 Generic/$50 Brand Name / $7 Generic/$35 Formulary Brand Name/$70 Non-Formulary Brand Name
True Out of Pocket Maximum – Includes Deductible, Coinsurance and Copays
Employee Contribution per Pay Period
Single / $0.00 / $87.00
Two Person / $0.00 / $207.00
Family / $0.00 / $259.00
NOTE: Employee Contribution Rates may be affected by a tobacco use surcharge. The surcharge will amount to $25.00 for a single tobacco user or $50.00 for more than one tobacco user per paycheck.

Behavioral Health Professionals, Inc. 2016-2017 Benefit Summary continued…

METLIFE DENTAL / VISION Included with Medical Plans
In Network / Out-of-Network / In Network / Out-of-Network
Deductible (applies to Class II & III only) Individual/Family / None / None / Eye Exam Deductible / $5 / Reimbursement up to $35 less a $5 copay
Class I: Preventative Services / 100% / 100% / Frames and Lenses Deductible / $10 / Reimbursement up to predetermined amount after copay
Class II: Basic Services / 90% / 80% / One eye exam, lenses, and frame in any period of 12 consecutive months. VSP Network.
Class III: Major Services / 60% / 50% / Must choose between contact lenses or prescription glasses.
Orthodontic Services (to age 19) / Discount at participating providers
Annual Maximum Benefit / $1,000
Employee Contribution per Pay Period
Single / $8.00
Two Person / $10.00
Family / $13.00
OTHER BENEFITS
Mutual of Omaha Life Insurance and Accidental Death and Dismemberment / BHPi provides coverage - 1 times your base salary to a maximum of $100,000.00.
Mutual of Omaha Long-Term Disability / BHPi provides coverage – the plan provides 60% of earnings to a maximum of $5,000.00 per month. Elimination period of 90 days.
Mutual of Omaha Additional Supplemental Insurance / Voluntary employee paid policies for Short-Term Disability, Term Life Insurance and Critical Illness.
Employee Assistance Program / This program offers resources to assist with questions, concerns or emotional issues surrounding either your personal or work life.
Travel Assistance / This program offers worldwide emergency travel assistance.
401(k) / The 401(k) retirement plan is available to employees after 6 months of service. The company matches 100% of the first 6% in eligible compensation deferred.
Parking / Free parking is available. An employee’s vehicle must have an agency parking sticker to identify employee vehicles from visitors/client vehicles.
Holidays / Paid Holidays (10): New Year’s Day, Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, Day after Thanksgiving, Christmas Eve, Christmas, One Floating Holiday.

This is intended as an easy-to-read summary. Please see the applicable certificates and riders for a complete description of benefits.

Benefit Plan Year December 1, 2016 to November 30, 2017.