nonparticipating deductible Out-of-pocket maximum nonparticipating out-of-pocket max Preventive care 100% 100% 100% 100%

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1 HumanaPPO 08 Louisiana 80/50 Copay plan SJBP Office of Fire Services Plan pays for services from PARTICIPATING providers Office visit copayment $20 primary care/$40 specialist Not applicable Plan pays for services from NONPARTICIPATING providers Deductible per calendar year copayments do not apply individual family $1,000 participating deductible $3,000 nonparticipating deductible Out-of-pocket maximum per calendar year deductibles and copayments do not apply individual family $2,000 participating out-of-pocket max $6,000 nonparticipating out-of-pocket max Preventive care preventive office visits after office visit copayment preventive lab and X-ray child immunizations age 6 to age 18 flu and pneumonia immunizations Pap smear and mammogram prostate screening child immunizations to age 6 50% endoscopic services (including, but not limited to colonoscopy) Physician services office visits after office visit copayment diagnostic lab and X-ray allergy testing injections (including allergy and serums) after $5 copayment per visit inpatient and outpatient services surgery emergency room visits Facility services inpatient and outpatient services outpatient advanced imaging (PET, MRI, MRA, CAT, SPECT) hospital, freestanding facility and clinic emergency services (copayment waived if admitted) after $150 copayment after $150 copayment Other medical services skilled nursing facility (up to 60 days per calendar year) hospice home health care (up to 100 visits per calendar year) physical, occupational, cognitive, speech and audiology therapy (combined limit up to 25 visits per calendar year) durable medical equipment urgent care after specialist copayment per visit spinal manipulations, adjustments and modalities after office visit copayment ambulance 80% after participating deductible maternity Same as any other illness Same as any other illness Mental health, chemical and alcohol dependency* transplant services inpatient services (up to 10 days per calendar year) outpatient and office therapy sessions (combined limit up to 15 visits per calendar year) * Chemical and alcohol dependency services are subject to Consumer Price Index. Same as any other illness when services are received from a Humana Transplant Network provider after specialist office visit copayment Same as any other illness. Covered expenses are limited to a maximum allowance of $35,000 per transplant continued on back

2 Plan pays for services from PARTICIPATING providers Plan pays for services from NONPARTICIPATING providers Louisiana 80/50 Copay plan Network Humana/ChoiceCare Network Humana s ChoiceCare Network is one of the largest, most cost-effective physician and hospital networks in the nation, and it s growing daily. This PPO network gives employees coast-to-coast access to favorably priced health care. Plus, Humana maintains strong provider relationships with local PPO networks for added coverage. Pharmacy Detailed drug lists are available at Humana.com for each pharmacy plan and level. Rx4 Retail (30-day supply) Level 1 Level 2 Level 3 Level 4 Mail order (up to 90-day supply) Copayment maximum (applies to Level 4 drugs only) $10 $35 $55 25% 2.5 times the retail copayment $2,500 per member per calendar year NOTE: If a nonparticipating pharmacy is used, the claim will be covered at 70 percent after applicable copayment. NOTICE: HEALTH CARE SERVICES MAY BE PROVIDED TO YOU AT A NETWORK HEALTH CARE FACILITY BY FACILITY- BASED PHYSICIANS WHO ARE NOT IN YOUR HEALTH PLAN. YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE OUT-OF-NETWORK SERVICES, IN ADDITION TO APPLICABLE AMOUNTS DUE FOR CO-PAYMENTS, COINSURANCE, DEDUCTIBLES, AND NON-COVERED SERVICES. SPECIFIC INFORMATION ABOUT IN-NETWORK AND OUT- OF-NETWORK FACILITY-BASED PHYSICIANS CAN BE FOUND AT THE WEBSITE ADDRESS OF YOUR HEALTH PLAN OR BY CALLING THE CUSTOMER SERVICE TELEPHONE NUMBER OF YOUR HEALTH PLAN. Insured by Humana Health Benefit Plan of Louisiana, Inc. This plan imposes a pre-existing condition exclusion. This is not a complete disclosure of plan qualifications and limitations. Before applying for coverage, please refer to the Regulatory Pre-enrollment Disclosure Guide for a description of plan provisions which may exclude, limit, reduce, modify or terminate your coverage. This guide is available at or through your employer. Premiums and benefits vary based on the plan selected Plan summary created on: 30/10/ :34:21 Policy number: CC2003-P

3 Humana Medical Plan Federal Mental Health Parity Addendum This addendum amends the Mental Health and Substance Abuse sections of your benefit summary in accordance with provisions of the national Emergency Economic Stabilization Act of 2008, HR The law is effective October 3, 2009 and applies to new or renewing groups with 51 or more total employees with an effective date of 11/01/09 or after. Please refer to your updated Benefit Plan Document, also known as Certificate, for specific mental health benefits of your plan. Mental Health Benefits Group health plans must ensure the following: Financial requirements Treatment limitations

4 Benefit summary changes for grandfathered plans due to federal health care reform The Patient Protection and Affordable Care Act, also known as federal healthcare reform, became law on March 23, Because of this law, health plans with a renewal date on or after Sept. 23, 2010 must meet certain guidelines. We re in the process of updating Humana benefit summaries to meet those guidelines. In the meantime, here s an overview of federal healthcare reform updates to your benefit summary. Lifetime maximum benefits The plan has an unlimited lifetime maximum. Annual dollar limits There are no annual dollar limits on covered essential health benefits, which include the following: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental and substance use disorder, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care Pre-existing conditions The pre-existing condition limitation will no longer apply to a covered person who is under the age of 19, but continues to apply to those age 19 or older. Emergency Care The plan covers services for an emergency medical condition provided in a hospital s emergency facility at the innetwork benefit level. Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # , Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # or administered by Humana Insurance Company or Humana Health Plan, Inc. For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company Statements in languages other than English contained in the advertisement do no necessarily reflect the exact contents of the policy written in English, because of possible linguistic differences. In the event of a dispute, the policy as written in English is considered the controlling authority. GNA09UFES 810

5 Cambios al resumen de beneficios para planes de salud exentos debido a la reforma federal al sistema de salud La Ley de Protección al Paciente y Cuidado de Salud de Bajo Precio, conocida también como Reforma Federal al Sistema de Salud, entró en vigencia el 23 de marzo de Según la ley, los planes de salud vendidos o renovados con vigencia el 23 de septiembre de 2010 o después, deben acatar ciertas normas. Mientras actualizamos los resúmenes de beneficios de Humana para cumplir dichas normas, le ofrecemos un boceto de las actualizaciones de la reforma federal al sistema de salud a su resumen de beneficios. Beneficios máximos de por vida El plan no tiene límites de por vida para los beneficios. Límites monetarios anuales No hay límites monetarios anuales a los beneficios esenciales de salud cubiertos, los que incluyen: Servicios para pacientes ambulatorios Servicios de emergencia Hospitalizaciones Maternidad y cuidado del recién nacido Trastornos mentales y adicciones, incluido el tratamiento de la salud del comportamiento Medicamentos recetados Servicios y dispositivos de habilitación o rehabilitación Servicios de laboratorios Servicios preventivos, de bienestar y de control de enfermedades crónicas Servicios pediátricos, incluida la atención dental y de la vista Afecciones médicas preexistentes La limitación por afección preexistente ya no se aplicará a una persona cubierta menor de 19 años, pero sigue vigente para personas de 19 años de edad o mayores. Atención médica de emergencia El plan cubre los servicios recibidos por una afección de emergencia en un centro médico de emergencias de un hospital, con un nivel de beneficios dentro de la red. Los planes de Humana se ofrecen a través de Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. No. de licencia: , Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc., una Organización para el Mantenimiento de la Salud (HMO) o asegurados por Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, o Humana Insurance of Puerto Rico, Inc. No. de licencia: o administrados por Humana Insurance Company o Humana Health Plan, Inc. En Arizona: Ofrecido por Humana Health Plan, Inc. o asegurado por Emphesys Insurance Company o asegurado o administrado por Humana Insurance Company Los enunciados que este documento contenga en otro idioma, que no sea el inglés, podrían no manifestar rigurosamente el significado de la póliza original debido a la posibilidad de diferencias lingüísticas. En caso de haber alguna discrepancia, la versión en inglés asumirá la validez exclusiva. GNA09UFES 810

6 GRANDFATHERED HEALTH PLAN NOTICE AVISO DEL PLAN DE SALUD EXENTO GRANDFATHERED HEALTH PLAN NOTICE Humana believes this plan is a grandfathered health plan under the Patient Protection and Affordable Care Act of 2010 (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to our customer service center at the telephone number on your identification card. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or This website has a table summarizing which protections do and do not apply to grandfathered health plans. Humana considera este plan como un plan de salud exento bajo la Ley de Protección al Paciente y Cuidado de Salud de Bajo Precio de 2010 (Affordable Care Act, en inglés). Según lo permitido por dicha ley, un plan de salud exento puede amparar cierta cobertura básica de salud que ya estaba vigente cuando la ley se decretó. Un plan de salud exento significa que su plan pudiera no incluir ciertas protecciones al consumidor de la Ley de Cuidado de Salud de Bajo Precio que se aplican a otros planes; por ejemplo, el requisito de suministrar servicios de salud preventivos sin ninguna participación del costo. Sin embargo, los planes de salud exentos deben cumplir con ciertas otras protecciones al consumidor incluidas en la Ley de Cuidado de Salud de Bajo Precio, por ejemplo, la eliminación de límites máximos de por vida a los beneficios. Si tiene preguntas sobre cuáles protecciones se aplican a un plan de salud exento y cuáles no, o qué pudiera ocasionar que un plan cambie su categoría como plan de salud exento, llame a nuestro centro de servicio al cliente al teléfono impreso en su tarjeta de identificación. También puede comunicarse con la Administración de Seguridad de Beneficios del Empleado del Departamento de Trabajo de Estados Unidos al o en la página Este sitio Web muestra una tabla en la que se resume cuáles protecciones se aplican, o no, a los planes de salud exentos. Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # , Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # or administered by Humana Insurance Company or Humana Health Plan, Inc. For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company Statements in languages other than English contained in the advertisement do no necessarily reflect the exact contents of the policy written in English, because of possible linguistic differences. In the event of a dispute, the policy as written in English is considered the controlling authority. Los enunciados que este documento contenga en otro idioma, que no sea el inglés, podrían no manifestar rigurosamente el significado de la póliza original debido a la posibilidad de diferencias lingüísticas. En caso de haber alguna discrepancia, la versión en inglés asumirá la validez exclusiva. GNA09UCES 810

7 Good news! Beginning July 1, HumanaVitality is available with new and renewing Humana medical plans. Please share the information below with your employees so they can learn more about HumanaVitality and how to get started. What if we made getting healthy fun and rewarding? We just did. You want to be healthier. You want to live longer. And you want better quality out of that life. HumanaVitality SM is here to help you do that. It s a groundbreaking program you can voluntarily use to really take charge of your health. Getting started is easy. Beginning July 1, you can start exploring all the benefits of HumanaVitality by logging in to your secure member page at Humana.com. If you are not registered, go to Humana.com, choose Register in the log-in box, and follow the instructions. When you register, you begin changing your life, working with HumanaVitality to understand your health today and find out what your risks are for tomorrow all in a safe, secure, and confidential manner. You get advice on what to eat and what kind of exercise makes sense for you. And the best part is, you are rewarded not only in health and happiness, but in perks you choose. With HumanaVitality, once you know where you stand, you set goals. We help you form good habits, like picking up fruits and vegetables at the market instead of chips. Or taking a walk instead of sitting on your couch. Healthy choices are recorded and earn you Vitality Points TM. And those points earn you rewards, like name-brand products, travel, and resort stays. It s just that simple. No matter what stage of life or health you re in, HumanaVitality is for you. HumanaVitality: A fun, rewarding wellness program that puts YOU front and center. SM Program details are subject to change. Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # , Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. - A Health Maintenance Organization, or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # , or administered by Humana Insurance Company or Humana Health Plan, Inc. For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company. GCHH1VSHH 4/11