Benefit SummaryPlan Year: December 1, 2013 to November 30, 2014

2OAP5 1.5K / 90 B In-Network Non-Network

Physician Office Visit Copay: • Primary Care• Specialist (No referral necessary)• Urgent Care• Global Maternity Physician Charge

$25 Copay$50 Copay$60 Copay

Deductible / Coinsurance

Deductible / Coinsurance

Calendar Year Deductible: • Individual• Family

$1,500$4,500

$3,000$9,000

Co-Insurance (after deductible you pay) 10% 40%

Out of Pocket Maximum (includes deductible) • Individual• Family

$4,500$9,000

$9,000$18,000

Prescription Drugs• Tier 1• Calendar Year Deductible• Tier 2 / Tier 3• Tier 4

• Mail Order – Tier 1 / Tier 2 / Tier 3• Tier 4

$15$200 per member

$40 / $7520% to max of $200

$15 / $80 / $22520% to max of $200

60% after deductible

Not Covered

If a member receives a brand name drug that falls on Tier 3 that has a generic equivalent available, the member pays the Tier 1 copay, plus the difference in cost between the brand drug and generic drug. This applies even when physician indicates DAW (dispense as written).

Provider Directory: BlueChoice Open Access ; www.bcbsga.com; Find a Doctor; best to use your 3 digit prefix; Blue Open Access POS

BCBS of Georgia - Medical Plan

Pay period Deduction (24pp) Employee Employee/Spouse Employee/Child(ren) Employee/Family

Medical $0 $227.10 $196.13 $423.22

Medical Plan In an effort to assist with potential out of pocket expenses, the firm will reimburse each employee up to $1,000.00 of his/her individual out-of-pocket expenses. For in-network services, the firm will pay the out-of-pocket expenses incurred from $3,501 to $4,500 which is the maximum amount of out-of-pocket expense, if applicable. For out of network services, the firm will pay the out-of-pocket expenses incurred also from $3,501 to $4,500, with the employee being responsible for the amounts incurred from $4,501 to $9,000, if applicable.

Employee Assistance

DENTAL Dental Option 1 – Scheduled Plan(If dentist is in-network)

Dental Option 2 – Unscheduled Plan(If dentist is not in-network)

In-Network Non-Network In-Network Non-Network

Payment Mode Paid at Contracted Rate Max. Allowable Charge Paid at Contracted Rate Paid at 90th percentile

Deductible $50 / waived for Preventive Care $50 / waived for Preventive Care

Co-Insurance 100% Preventive / 100% Basic / 60% Major50% Ortho

100% Preventive / 80% Basic / 50% Major50% Ortho

Plan Maximum $1,000 Annual Maximum / per insured$1,000 Orthodontia Lifetime Maximum

$1,000 Annual Maximum / per insured$1,000 Orthodontia Lifetime Maximum

Preventive Routine exams, cleanings (2 per year), second opinion consults, fluoride treatment, space maintainers, sealants, x-rays

Routine exams, cleanings (2 per year), second opinion consults, fluoride treatment, space maintainers, sealants, x-rays

Basic Periodontic prophylaxis, fillings, stainless steel crowns, general anesthesia, simple oral surgery, complex oral surgery,

periodontics, endodontics

Periodontic prophylaxis, fillings, stainless steel crowns, general anesthesia, simple oral surgery, complex oral surgery, periodontics,

endodontics

Major Repairs to partial denture, bridge crown, crowns, inlays, onlays, cast post and core, bridges, dentures

Repairs to partial denture, bridge crown, crowns, inlays, onlays, cast post and core, bridges, dentures

Rollover Benefit Threshold $500; Rollover amount: $250; Account Limit $1,000 Threshold $500; Rollover amount: $250; Account Limit $1,000

Principal – Dental and Vision

Pay Period Deduction (24pp) Employee Spouse Child(ren) Family

Dental $0 $15.34 $26.83 $48.60

Vision $0 $5.00 $4.41 $9.41

Vision – free to use any provider; benefits are available once per 12 months

Eye Exams Up to $65 for eye exam;

Frames Allowance / Contact Lens Allowance Frames: up to $150; Contact Lenses: up to $200

Lenses $50 for Single lenses; $75 for Bifocal lenses; $100 for Trifocal lenses; $150 for Lenticular lenses

Benefits Begin

Benefits Payable

Maximum

Duration

Own Occupation

Determine your premium

Rates

Less than age 25

25 – 29

30 – 34

35 – 39

40 – 44

45 – 49

50 – 54

55 – 59

60 – 64

65 and over

Voluntary Short-term Disability

15 Days Accident or Illness

60% of pre-disability earnings

$2,000 Weekly Maximum

Payable up to 11 weeks

N/A

Annual earnings / 52 = weekly earningsWeekly earnings x .60 = weekly benefit

Weekly benefit / 10 x (rate ______) = monthly costMonthly cost x 12 / 24 = payroll deduction $_____(note: if your weekly benefit exceeds $2,000; then

use$2,000 as your weekly benefit.

.40

.44

.39

.36

.38

.39

.46

.58

.71

.79

Voluntary Long-term Disability

90 Days

60% of pre-disability earnings

$10,000 Monthly Maximum

Payable to Social Security Normal Retirement Age

Class I: Attorneys: SSNRA Class II: All Others: 24 Months

Annual earnings / 12 = monthly earningsMonthly earnings / 100 x (rate _____) = monthly cost

Monthly cost x 12 / 24 = payroll deduction $_____(note: if your monthly earnings exceed $16,666; then

use $16,666 as your monthy earnings.

.09

.14

.26

.41

.65

.87

1.12

1.29

1.18

.69

Unum Insurance

The information contained in this benefits summary is incomplete. Please refer to the certificate of insurance or plan document for coverage terms, conditions, limitations and exclusions. If there is any difference between the contents of this summary and the policy, plan or proposal to which it addresses, the language of the policy, plan or proposal shall rule. Non-network care and treatment is subject to usual, reasonable and customary provisions that may result in reduced reimbursement. Should you have any questions please contact Jennifer Bent, Christine Gottfried, or me, Cindy Nash. Thank you!

Cindy L. NashAngus McRae Insurance Brokerage Services, Inc.4725 Peachtree Corners Circle, Suite 155Norcross, GA 30092cnash@angusmcrae.com(770) 300-0001 ext. 102 (phone)(770) 366-6896 (mobile)(770) 456-5059 (fax)