SCHEDULE OF BENEFITS FOR STANDARD PLAN Benefit Plan 207

Major Medical Benefits (Associates and Dependents)

Individual Lifetime Maximum

$750,000

Maximum Hospital Daily Benefit

Semi Private

Charge of semi-private room of which hospital has greatest number will be paid toward private room.

Number of Days per Confinement

Unlimited

Deductible Amount Per Calendar Year

Single

2 Member Family

3 or more Member Family

Percent of Company Participation after Deductible

Out-of-Pocket Maximum Per Calendar Year (Includes Deductible)

Single

Family

Hospitalization

Number of Inpatient Days

X-Ray, Lab and Miscellaneous Hospital Services in a:

•       Hospital (Inpatient and Outpatient)

•       Skilled Nursing Facility

•       Outpatient Surgery Facility

Pre-Certification Required for All Inpatient Hospital Confinements

Surgery Services (Including Inpatient and Outpatient)

Second Surgical Opinion (Elective Non-Emergency Surgeries)

Physician Visits

Hospital

Office

Radiation Therapy

Maternity (Includes coverage for dependent daughters)

Emergency Care

Mental Health and Alcoholism/Substance Abuse

Inpatient/Transitional Treatment

Outpatient

Short Term Rehabilitation Therapy

Physical

Occupational

Speech

Chiropractic Services

Preventative Care (Includes x-rays and lab tests in connection with exam)

Well Baby Care, including immunizations, the first 6 visits will not apply to the maximum (Birth to 6 years of age)

Routine Physical Exam (over age 6)

Pap Smears

Mammograms

Tuberculosis Testing (to age 19)

X-ray and Lab Tests

Allergy Care

Ambulance

Durable Medical Equipment

Oral Surgery

Vision Care Eye Exams (for illness or injury only)

Lenses

Frames

Contact Lenses

Hearing Exams

Health Education & Counseling

Hospice Care

Impatient

Outpatient

Bereavement Counseling

Skilled Nursing Home

Home Health Care

Family Planing Elective Sterilization

Prescription Drugs

Copay Waived with Drug Card