MEDICAL PLAN BENEFIT – See SECTIONS 5.1 THROUGH 5.18 Benefit Funded by the Trust Lifetime Maximum Benefit For Eligible Employee and their Dependents - $1,000,000 For Retired Participants and their Dependents - $500,000 Lifetime Maximum for Treatment of Substance Abuse - $50,000 Maximum Restoration of Benefits Paid in Calendar Year - $10,000 Calendar Year Deductible For Eligible Employees and their Dependents Per Participant - $100 Per Family - $200 For Retired Participant and their Dependents Each Participant WITH Medicare - $200 Each Participant WITHOUT Medicare - $2,000 Annual Out-of-Pocket Limit For Eligible Employees and their Dependents Per Participant - $2,000 Per Family - $4,000 For Retired Participant and their Dependents Each Participant WITH Medicare - $1,500 Each Participant WITHOUT Medicare - $6,000 Hospital Services (inpatient and outpatient) Preferred Providers % of Covered Expenses Non-Preferred Provider % of contract rates Hospitals in Alaska, in Anchorage 80% 70% of rate negotiated with Preferred Provider; after additional $1,000 inpatient deductible Hospitals in Alaska, outside Anchorage 80% 70% Hospitals outside of Alaska 80% 70% Preadmission Testing 100% 100% Professional Services and Supplies Physician visits (home, office, or hospital visits) 80% 70% Surgeon and assistant surgeon 80% 70% Diagnostic x-rays, laboratory testing 80% 70% Chiropractic office visits (up to 10 visits per year) 80% 70% Physical or occupational therapy (up to 20 visits per year) 80% 70% Speech therapy or cardiac rehabilitation (up to 20 visits per year) 80% 70% Medical equipment and prosthetics 80% 70% Home Health Care Benefit 80% 70% All Hospital confinements are subject to Precertification Review.   % of Covered Expense Skilled Nursing Facility 80%; up to 365 days Hospice Care 80% Surgeries performed at a non-Preferred Provider facility in the Anchorage area may be payable at 70% of the rate negotiated with a Preferred Provider. In addition, certain Surgical procedures may be covered at 50% if performed on an inpatient basis. Refer to the COVERED EXPENSES section of this Booklet.   % of Covered Expense Preventive Health Care (Refer to Section 5.14) Routine Physical Examination Well Child Care Immunizations 100%; up to $300 per calendar year; subject to UCR 100%; up to $300 per calendar year 100%; up to $500 per calendar year Ambulance Service 70% Hearing Loss Benefit 70%; up to $800 per ear during any 3 consecutive years Treatment for Mental Illness/Substance Abuse   Inpatient facility charge Paid as Hospital Service Inpatient provider treatment 50% of Covered Expenses, not subject to the annual deductible and balance does not apply to the annual out-of-pocket limit Outpatient treatment 50% of Covered Expenses, not subject to the annual deductible and balance does not apply to the annual out-of-pocket limit Inpatient detoxification limitation 3 days per confinement; lifetime limit of 2 confinements Inpatient treatment limitation 30 days per calendar year Outpatient treatment limitation 26 visits per calendar year Maximum Lifetime Benefit for Substance Abuse $50,000 per Participant