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Plan Benefit Code
Plan Benefit - AZ Cap/Eligibility CP7810 Assigned Plan Benefit Codes & Descriptions State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit 22A 22D 22F 22G 2AA 2AC 2AD 2AE 2AF 2AG 2AH 2AN 2AX 2AY 2BL 2DK 2FH 2FL 2GH 2HH 2JH 2KH 2MH 2NH 2PH 2QH 2UH 2VH 2WH 2XH 2YH 2ZA 2ZB 2ZC 2ZD 2ZE 2ZF 32B 33B 3AA 3AB 3AC Plan / Benefit Description 3/3 BO IAM GR-RX05 7/7 BOEING GR-RX05 7/20 ADOA GR-RX05 10/20 ASRS GR-RX05 5/15L SH-RX05 7/14 GR-RX05 10/20 GR-RX05 10/25L GR-RX05 7/14 I GR-RX05 10/20 I GR-RX05 10/25L I GR-RX05 4/20/40 LO GR-RX07 20/40 GR-RX07 4/25/50 HI GR-RX07 10/25/50 RX-GR08 20/40 GR-RX07 4/15/30 RX-GR08 5/20/45 RX-GR08 4/20/40 RX-GR08 4/15/30 RX-GR08 4/20/40 RX-GR08 4/25/50 RX-GR08 4/25/45 RX-GR08 4/28/55 RX-GR08 4/2/58 RX-GR08 4/25/50 RX-GR08 10/25/50 RX-GR08 10/25/50 RX-GR08 5/20/45 RX-GR08 5/20/45 RX-GR08 4/10/20 RX-GR08 0/0 GR-RX07 2/40 GR-RX07 5/25 GR-RX07 5/65 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 5/15/30 BO GR-RX05 5/15/30 BO RX-GR08 10/25/50L SH-RX05 10/30/55L SH-RX05 10/20/40 GR-RX05 1 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit 3AD 3AE 3AG 3AH 3AJ 3BK 3LL 3ZE 3ZF 3ZG 3ZH 3ZJ 3ZK 3ZL 3ZM 42G 42H 43D 43H 4AA 4XQ 6AA 6AB 6AH 6AL 6AQ 6BH 6BL 6DH 6DL 6ED 6EH 6EL 6EP 6ER 6FH 6FL 6FP 6GP 6HH 6HL 6HP 6JH 6JL 6KH 6KL 6KP 6LH 6LL 6MA Plan / Benefit Description 15/25/40L GR-RX05 15/25/40 GR-RX05 10/20/40 I GR-RX05 15/25/40L I GR-X05 15/25/40 I GR-RX05 10/30/50 GR-RX07 10/20/50 GR-RX07 5/10/20 GR-RX07 10/20/35 GR-RX07 10/20/35 GR-RX07 10/25/55 GR-RX07 10/40/75 GR-RX07 7/20/50% GR-RX07 2/30/60 GR-RX07 10/25/50 GR-RX07 MCC 1 PIMA GR08 MCC 1 PIMA DLX GR08 MCC 3 MCOPA GR08 MCC 3 MCOPA DLX GR08 SV 15/30/250A NAT'L 05 5/29/60 W/G GR-RX7 SV 10/100% 05 SP 10/100% 05 0/0 HI GR-RX07 0/0 LO GR-RX07 7/20 GR-RX06 2/30/60 HI GR-RX07 2/30/60 LO GR-RX07 2/40 HI GR-RX07 2/40 LO GR-RX07 7/7 GR-RX06 5/25 HI GR-RX07 5/25 LO GR-RX07 8.50/26.40/50% SH6 10/20 GR-RX06 5/65 HI GR-RX07 5/65 LO GR-RX07 8.50/26.40/50% SH6 8.50/26.45/50% SH6 5/10 HI GR-RX07 5/10 LO GR-RX07 8.50/26.45/50% SH6 5/10/20 HI GR-RX07 5/10/20 LO GR-RX07 7/14 HI GR-RX07 7/14 LO GR-RX07 8.50/26.70/50% SH6 7/20/50% HI GR-RX7 7/20/50% LO GR-RX7 10/25%/40% RX-GR06 2 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit 6MH 6MI 6ML 6MR 6NH 6NL 6NM 6PH 6PL 6PP 6QH 6QL 6QP 6RH 6RL 6SH 6SL 6TH 6TL 6TP 6UH 6UL 6VM 6VP 6WH 6XM 6YM 6ZR 7AA 7AQ 7AR 7BD 7BH 7BI 7BL 7BR 7CD 7CI 7CM 7DD 7DH 7DL 7DM 7DR 7ED 7EH 7EL 7EM 7ER 7FD Plan / Benefit Description 10/20 HI GR-RX07 10/20/40 I GR-RX06 10/20 LO GR-RX07 10/20/40 GR-RX06 10/20/40 HI GR-RX7 10/20/40 LO GR-RX7 5/15/30 GR-RX06 10/20 HI GR-RX07 10/20 LO GR-RX07 8.50/26.85/50% SH6 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 8.50/26.85/50% SH6 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 10/25/55 HI GR-RX7 10/25/55 LO GR-RX7 10/40/75 HI GR-RX7 10/40/75 LO GR-RX7 4.50/14.50/50% SH6 15/25/40 HI GR-RX7 15/25/40 LO GR-RX7 5/5 GR-RX06 25%/25%/25% SH6 10/25/50 HI GR-RX7 7/14 GR-RX06 7/14 GR-RX06 15/25/40 GR-RX06 SV 15-25/250A PIMA 05 7/20 GR-RX07 0/0 GR-RX07 7/14 GR-RX07 4/10/20 T1A H GRX7 7/14 I GR-RX07 4/10/20 T1A L GRX7 0/0 FLAT GR-RX07 7/14 GR-RX07 7/14 I GR-RX07 15/25/40 GR-RX07 7/20/30 GR-RX07 4/15/30 T1B H GRX7 4/15/30 T1B L GRX7 15/25/40 GR-RX07 10/10 FLAT GR-RX07 7/7 GR-RX07 4/20/40 T1C H GRX7 4/20/40 T1C L GRX7 3/3 FLAT GR-RX07 10/20 GR-RX07 7/7 C GR-RX07 3 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit 7FH 7FL 7FM 7FR 7GD 7GM 7GR 7HH 7HI 7HL 7HR 7JH 7JL 7JM 7JR 7KH 7KI 7KL 7KM 7KR 7LH 7LL 7LM 7LR 7MA 7MH 7MI 7ML 7MR 7NH 7NL 7NM 7PH 7PI 7PL 7PM 7PR 7Q2 7Q3 7Q4 7QH 7QI 7QL 7QM 7QR 7RA 7RB 7RC 7RD 7RH Plan / Benefit Description 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 3/3/3 GR-RX07 10/20 GR-RX07 10/20/30 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 4/15/30 T2A H GRX7 10/20 I GR-RX07 4/15/30 T2A L GRX7 10/20 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/10 GR-RX07 10/10 GR-RX07 4/28/55 T3B H GRX7 10/20/35 I GR-RX07 4/28/55 T3B L GRX7 5/10/20 GR-RX07 10/20/35 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 5/15 GR-RX07 15/25/40 GR-RX07 10/25%/40% GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 10/20/40 GR-RX07 4/25/50 T2C H GRX7 4/25/50 T2C L GRX7 5/15/30 GR-RX07 4/25/50 T2C H GRX7 10/20/40 I GR-RX07 4/25/50 T2C L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 5/29/56.25W/G SHX7 5/29/55.40W/G SHX7 5/29/56.20W/G SHX7 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 4/15/30 T2A H GRX7 4 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit 7RL 7RM 7SB 7SI 7SR 7TH 7TL 7TM 7TR 7UH 7UL 7UM 7UR 7VH 7VL 7VM 7WH 7WI 7WL 7WM 7WR 7XA 7XB 7XC 7XD 7XE 7XF 7XG 7XH 7XJ 7XL 7XM 7XP 7XZ 7YH 7YI 7YL 7YM 7YR 7ZH 7ZL 7ZM 7ZR 82A 82B 82C 82D 82E 82F 82G Plan / Benefit Description 4/15/30 T2A L GRX7 5/15/30 GR-RX07 10/25%/40% GR-RX07 10/20/40 I GR-RX07 10/20/40 GR-RX07 4/28/55 T3B H GRX7 4/28/55 T3B L GRX7 5/5 GR-RX07 10/25/40 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/5 GR-RX07 15/25/40 GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 5/5 GR-RX07 4/20/40 T1C H GRX7 15/25/40 I GR-RX07 4/20/40 T1C L GRX7 5/7.50 GR-RX07 15/25/40 GR-RX07 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/25/50 RDS GR-RX7 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/15/30 T1B H GRX7 4/25/50 RDS GR-RX7 4/15/30 T1B L GRX7 7/14 GR-RX07 5/29/60 N/G SH-RX7 5/35/65 NGE SH-RX7 4/10/20 T1A H GRX7 15/25/40 I GR-RX07 4/10/20 T1A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit 82H 82J 82K 82L 82M 82N 82P 82Q 82R 82S 82T 82U 82V 82W 82X 82Y 82Z 83A 83B 83C 83D 83E 83F 83G 83H 83J 83K 83L 83M 8AA 8AB 8AC 8AH 8AR 8B8 8BH 8CH 8D8 8DD 8DH 8DR 8ED 8EH 8EM 8ER 8FD 8FH 8GH 8GM 8HD Plan / Benefit Description 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 SV 20-40/500A 05 SP 20-40/500A 05 SV 20-40/80%A 05 0/0 HI C GR-RX07 0/0 C GR-RX07 5/29/60NG RX-SH08 DO NOT USE 2/30/60 HI C GRX07 6/40/80NG RX-SH08 7/20/30 C GR-RX07 2/40 HI C GR-RX07 10/10 FLAT C GRX07 7/7 C GR-RX07 5/25 HI C GR-RX07 3/3 FLAT C GR-RX07 10/20 C GR-RX07 7/7 C GR-RX07 5/65 HI C GR-RX07 5/10 HI C GR-RX07 5/10 C GR-RX07 10/20/30 C GR-RX07 6 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit 8HH 8KM 8LH 8LM 8MA 8NM 8PH 8PM 8RH 8RM 8SH 8TH 8TM 8TR 8UM 8UR 8VM 8WH 91H 92H 93H 94H 95H 9AN 9AQ 9AR 9AX 9AY 9BE 9BH 9BK 9BL 9CM 9DH 9DK 9DL 9DR 9EH 9EL 9ER 9FD 9FH 9FL 9GE 9GM 9HD 9HH 9HK 9HL 9HN Plan / Benefit Description DO NOT USE 5/10/20 C GR-RX07 7/20/50% HI C GRX7 5/15 C GR-RX07 10/25%/40% C GRX07 5/15/30 C GR-RX07 10/20 HI C GR-RX07 5/15/30 C GR-RX07 10/20/35 HI C GRX7 5/15/30 C GR-RX07 10/25/55 HI C GRX7 10/40/75 HI C GRX7 5/5 C GR-RX07 10/25/40 C GR-RX07 5/5 C GR-RX07 15/25/40 C GR-RX07 5/7.50 C GR-RX07 10/25/50 HI C GRX7 15/25/40 HI GR-RX8 10/25/50 HI GR-RX8 10/20/40 HI GR-RX8 10/20 HI GR-RX08 10/40/75 HI C GRX8 4/20/40 LO GR-RX08 7/20 GR-RX08 0/0 GR-RX08 20/40 GR-RX08 4/25/50 HI GR-RX08 7/14 GR-RX08 4/10/20 T1A H GRX8 10/30/50 GR-RX08 4/10/20 T1A L GRX8 15/25/40 GR-RX08 4/15/30 T1B H GRX8 20/40 GR-RX08 4/15/30 T1B L GRX8 10/10 FLAT C GRX08 4/20/40 T1C H GRX8 4/20/40 T1C L GRX8 10/20 GR-RX08 7/7 C GR-RX08 4/25/50 T1D H GRX8 4/25/50 T1D L GRX8 10/20/30 GR-RX08 5/10 GR-RX08 10/20/30 C GR-RX08 4/15/30 T2A H GRX8 4/10/20 RX-GR08 4/15/30 T2A L GRX8 4/15/30 RX-GR08 7 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit 9JH 9JL 9KH 9KL 9KS 9KY 9LH 9LL 9LM 9LP 9LR 9LV 9MA 9MH 9MI 9ML 9MR 9NH 9NL 9NM 9PH 9PL 9PX 9QH 9QL 9RH 9RL 9RP 9RX 9TH 9TL 9UH 9UL 9VH 9VL 9VM 9WH 9WI 9WL 9WM 9XH 9XL 9YH 9YL 9ZH 9ZL A3Q A3R A3T A3U Plan / Benefit Description 4/28/58 T3C H GRX8 4/28/58 T3C L GRX8 4/28/55 T3B H GRX8 4/28/55 T3B L GRX8 10/20/35 GR-RX08 10/20/40 RX-GR08 4/25/45 T3A H GRX8 4/25/45 T3A L GRX8 5/15 C GR-RX08 5/15 GR-RX08 10/20/50 GR-RX08 10/20/35 RX-GR08 10/25%/40% GR-RX08 4/20/40 T2B H GRX8 10/20/40 I GR-RX08 4/20/40 T2B L GRX8 10/20/40 GR-RX08 4/25/50 T2C H GRX8 4/25/50 T2C L GRX8 5/15/30 GR-RX08 4/25/50 T2C H GRX8 4/25/50 T2C L GRX8 5/29/60 P RX-GR08 4/20/40 T2B H GRX8 4/20/40 T2B L GRX8 4/15/30 T2A H GRX8 4/15/30 T2A L GRX8 5/15/30 GR-RX08 NO RX 4/28/55 T3B H GRX8 4/28/55 T3B L GRX8 4/28/58 T3C H GRX8 4/28/58 T3C L GRX8 4/25/50 T1D H GRX8 4/25/50 T1D L GRX8 5/5 GR-RX08 4/20/40 T1C H GRX8 15/25/40 I GR-RX08 4/20/40 T1C L GRX8 5/7.50 GR-RX08 4/15/30 T1B H GRX8 4/15/30 T1B L GRX8 4/10/20 T1A H GRX8 4/10/20 T1A L GRX8 4/25/45 T3A H GRX8 4/25/45 T3A L GRX8 ENHNCD CODE NOT USED ENHNCD CODE NOT USED ENHNCD CODE NOT USED ENHNCD CODE NOT USED 8 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit A3V A3W A3X A3Y A4C A4D A4E A4F A4G A4K A4M A4N A4P A4Q A4R A4S A4T A4U A4V A4X A5A A5B A5C A5D A5E A5F A5G A5H A5K A5M A5N A5P A5Q A5R A5S A5U A6G A6S A6W A6X ADK ADT APF APN ARK ASK ASR AT7 ATQ ATU Plan / Benefit Description ENHNCD MARCOPA GR07 ENH MARCOPA GOLD GR07 ENH MARCOPA SILVER GR07 ENH MARCOPA DELUXE GR07 ENH PIMA GOLD GR07 ENH PIMA SILVER GR07 ENH PIMA DELUXE GR07 ENHNCD PIMA GR07 ENH PIMA GOLD GR07 ENH PIMA SILVER GR07 ENH PIMA DELUXE GR07 ENHNCD CODE NOT USED ENHNCD CODE NOT USED ENHNCD CODE NOT USED ENHNCD CODE NOT USED ENHNCD PIMA GR07 ATW-STD GR-WL07 ENH PIMA GOLD GR07 ENH PIMA SILVER GR07 ENH PIMA DELUXE GR07 ENHNCD PINAL GR07 ENH PINAL EP GR07 ENH PINAL PP GR07 ENH PINAL DELUXE GR07 ENHNCD PINAL GR07 ENH PINAL EP GR07 ENH PINAL PP GR07 ENH PINAL DELUXE GR07 ENHNCD CODE NOT USED ENHNCD CODE NOT USED ENHNCD CODE NOT USED ENHNCD CODE NOT USED ENHNCD PINAL GR07 ENH PINAL EP GR07 ENH PINAL PP GR07 ENH PINAL DELUXE GR07 ARP MCC 1 PIMA GLD SH08 ARP MCC 1 PIMA SLVR SH08 ARP MCC 1 PIMA SH08 ARP MCC 1 PIMA DLX SH08 10-20/500A ADOA GR07 10-20 ADOA NON-AARP GR08 10/12V 1YR ACU SH07 10/12V 1YR ACU SH08 ENHNCD PINAL GR07 15-30 ASRS NON-AARP GR08 15-30/100A ASRS GR07 ATW-STD SH-WL07 ATW ENHANCED SH08 ATW-PLUS WL-SH08 9 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit ATV BDA BDL BOQ BPT BVH BVZ BWG C11 C27 C7A C7E C7F C7G C7H C7J C7K C7L C7M C7P C7S C7U C7W C7Y CAA CAB CAC CAD CAE CFP CFV CG2 CGG CGI CGL CGR CGS CGU CGV CGX CHU CHW COT CPA CRR CT6 CTU CZA CZB CZC Plan / Benefit Description ATW-STD WL-SH08 0/250A BOEING IAM725 GR 06 0 BO IAM 725 NO-AARP GR08 15 BO 148 NO-AARP GR08 20/100% BP AMOCO GR06 15 BO-VEBA NON-AARP GR08 15/100A BOEING VEBA GR07 20 BP AMOCO NON-AARP GR08 CONTACT BEHAVIORAL HEALTH SC 90 ELIGIBILITY ONLY 5/12V 1YR GR-CH07 10/12V 1YR GR-CH07 10/20V 1YR GR-CH07 10/30V 1YR GR-CH07 15/12V 1YR GR-CH07 15/20V 1YR GR-CH07 0/20V 1YR GR-CH07 15/30V 1YR GR-CH07 20/12V 1YR GR-CH07 5/10V 1YR GR-CH07 30/12V 1YR GR-CH07 5/20V 1YR GR-CH07 5/30V 1YR GR-CH07 5/40 1YR GR-CH07 5/12V TRIO SH-CH05 5/12V GR-CH05 15/12V GR-CH05 20/12V GR-CH05 10/12V GR-CH05 10 CFI-VEBA NON-AARP GR08 10/100% CFI VEBA GR07 CAREGIVER ENHANCED SH05 CAREGIVER - GOLD SH05 CAREGIVER SH05 CAREGIVER LITE SH06 CAREGIVER - RESPITE SH05 CAREGIVER GR05 CAREGIVER-RESPITE CG-SH08 CAREGIVER CG-GR08 CAREGIVER ENHANCED 10/12V 1YR SH-CH07 10/12V 1YR CH-SH08 10-20/350A C TUCSON GR07 RESERVED PFFS 10/12V GR-CH07 30/12V GR-CH06 10-20 TUCSON NON-AARP GR08 10/12V GR-CH05 15/12V BO-148 GR-CH05 10/12V BO-HRLY GR-CH05 10 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit CZD CZE D4R D4U D4V D4W D4X D6V D8A D8E D8G D8H D8W D8Y DA6 DAA DAB DB6 DBA DJ6 DMA DMB DN2 DN3 DNE DNY DP6 DQ6 DRR EAE EC4 ERO F4T FSL FTL H4J H4L H4U H4X H6P H8B H8D H8J H8K HAA HAB HAC HAD HAG HAK Plan / Benefit Description 15/12V BO-HRLY-F GR-CH05 10/12V BO-837 GR-CH05 $0 466 GR-DN07 $20 469 GR-DN07 SILVER GR-DN07 GOLD GR-DN07 DELUXE OPTION GR-DN07 DENTAL - VISION GR06 DELUXE OPTION DN-SH08 $20 469 DN-SH08 GOLD DN-SH08 SILVER DN-SH08 $0 466 DN-SH08 EC P&C 200 1YR DN-SH08 SILVER SH-DN06 15 SILVER SH-DN05 25 GOLD SH-DN05 GOLD SH-DN06 100%/70% DISCOUNT GR-DN07 $0 466 SH-DN06 20% SH-DM05 0 SH-DM05 SO 460 GRP BILLED - GR SO 462 INDIV BILLED - GR EVERCARE $5 SH-DN07 DELUXE OPTION SH-DN07 $5 PREVENTIVE SH-DN06 $20 469 SH-DN06 10-20/200A DERP GR07 EVERCARE DH SH08 EVERCARE DH SH07 EVERCARE DH-D SH08 THIS CODE CANCELLED SILVER SNEAKER SH/GR-WL07 SILVER SNEAKER SH/GR-WL08 0/500A 3YRS GR-HA07 0/400A 3YRS GR-HA07 0/1300A 3YRS DX GR-HA07 0/1200A 3YRS DX GR-HA07 15-25/100A GR06 0/1300A 3YRS DX HA-SH08 0/800A 3YRS DX HA-SH08 5/400A 3YRS HA-SH08 0/600A 2YRS DX HA-SH08 0/400A 3YR SH-HA05 0/300A 2YR GR-HA05 0/500A 2YR GR-HA05 0/500A 3YR GR-HA05 0/400A 3YR SH-HA05 NP 0/0A 3YR GR-HA05 11 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit HAM HAN HBJ HD6 HDE HF6 HHE HJC HL8 HOA HOE HOI HPE HRB HRD HRE HRR HRY HTC HWC LAD LAL LCE LCN LCP LCU LCW LCX LCY LDD LDE LDN LDP LEE LEN LEP LGD LGE LGN LGP LJ8 LND LNE LNN LNP LOK LOL LRI MBG MBS Plan / Benefit Description 1000A PER YR GR-HA05 300A/24M GR-HA07 HEARING AID $500 EVERY 3YR 5/400A 3 YRS SH-HA06 300A 2YRS HA-GR08 25/400A 3 YRS SH-HA06 500A 3YRS HA-GR08 0/0A 3YR HA-GR08 400A 3YRS 0PREM HA-GR08 RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED PFFS 0/500A 3YRS SH-HA07 0/800A 3YRS DX SH-HA07 5/400A 3YRS SH-HA07 300A GR-HA07 0/1300A 3YRS DX SH-HA07 500A 2YRS HA-GR08 1000A PER YR HA-GR08 20-30/250A LOKHEED GR06 15/100% LACERS GR07 10/30 PINAL C SH06 EPO 10/30 PINAL C SH06 10/30 PINAL C SH06 ODP ARP MCC 1 PINAL PP SH08 ARP MCC 1 PINAL SH08 ARP MCC 1 PINAL DLX SH08 ARP MCC 1 PINAL EP SH08 MCC 1 PINAL DELUXE SH07 MCC 1 PINAL EP SH07 MC COMP 1 PINAL SH07 MCC 1 PINAL PP SH07 5/10 PINAL CE SH06 EPO 5/10 PINAL CE SH06 5/10 PINAL CE SH06 ODP MCC 2 PINAL DELUXE SH07 MCC 2 PINAL EP SH07 MC COMP 2 PINAL SH07 MCC 2 PINAL PP SH07 15 LACERS NON-AARP GR08 MCC ESS PINAL DELUXE SH07 MCC ESS PINAL EP SH07 MC COMP ESS PINAL SH07 MCC ESS PINAL PP SH07 20-30/250A LOKHEED GR07 20-30 LOKHEED NON-AARP GR8 LIABILITY/RECOVERY INFO ARP MCC 1 MCOPA GLD SH08 ARP MCC 1 MCOPA SLVR SH08 12 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit MBW MBX MCE MCG MCN MCS MEE MEG MEN MES MGN MJD MJG MJN MJS MLD MLG MLN MLS MQD MQG MQN MQS MRD MRG MRN MRS MTK MTM MVG MVS MVW MVX MXG MXS MXW MXX NL8 NTB NTL O1Q O1R O1W O2A O2K O2M O2Q O2R O2S O2T Plan / Benefit Description ARP MCC 1 MCOPA SH08 ARP MCC 1 MCOPA DLX SH08 10/30 MARICOPA C SH06 EPO 10/30 MARICOPA C SH06 GOLD 10/30 MARICOPA C SH06 10/30 MARICOPA C SH06 SLVR 5/10 MARICOPA CE SH06 EPO 5/10 MARICOPA CE SH06 GOLD 5/10 MARICOPA CE SH06 5/10 MARICOPA CE SH06 SLVR 0/0 SECURE GOLD SH06 MCC 3 MARCOPA DELUXE SH07 MCC 3 MARCOPA GOLD SH07 MC COMP 3 MARCOPA SH07 MCC 3 MARCOPA SILVER SH07 MCC ESS MARCOPA DELUX SH07 MCC ESS MARCOPA GOLD SH07 MC COMP ESS MARCOPA SH07 MCC ESS MARCOPA SLVER SH07 MCC 1 MARCOPA DELUXE SH07 MCC 1 MARCOPA GOLD SH07 MC COMP 1 MARCOPA SH07 MCC 1 MARCOPA SILVER SH07 MCC 2 MARCOPA DELUXE SH07 MCC 2 MARCOPA GOLD SH07 MC COMP 2 MARCOPA SH07 MCC 2 MARCOPA SILVER SH07 10/5V 1YR MSG THRPY SH07 10/5V 1YR MSG THRPY SH08 ARP MCC 3 MCOPA GLD SH08 ARP MCC 3 MCOPA SLVR SH08 ARP MCC 3 MCOPA SH08 ARP MCC 3 MCOPA DLX SH08 ARP MCC ES MCOPA GLD SH08 ARP MCC ES MCOPA SLVR SH08 ARP MCC ES MCOPA SH08 ARP MCC ES MCOPA DLX SH08 24HR NURSLINE WL-SH/GR08 0/24-1W NON-ER TRANS SH07 0/24-1W NON-ER TRANS SH08 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 0/100% BOEING-GR05 10/100% BOEING HRLY-GR05 15/100% BOEING HRLY-F-GR05 10-20/750A T2A GR07 15-25/200D T3A GR07 15/200A BOEING 148-GR05 10-20/100% ASRS-GR05 13 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit O2W O33 O3D O3Q O3R O3W O4Q O4R O4W O5Q O5R O5W O6Q O6R O6W O7Q O7R O7W O8K O8Q O8R O8W O9Q O9R O9W OBC OBL OC1 OC3 OC5 OD3 ODE ODF ODG ODK OE1 OE3 OEB OEC OEE OF1 OF3 OF5 OG1 OG3 OG5 OH1 OH3 OH5 OJ8 Plan / Benefit Description 10-15/50A T1A GR07 10/100% NAT'L-GR06 10/100% NAT'L-GR06 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 10 BO HRLY NO-AARP GR08 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 10/100% NON-AARP GR08 10 SDCERA NON-AARP GR08 5/100% NAT'L GR 06 5/100% NAT'L GR 06 5/100% NAT'L GR 06 10/100% NAT'L GR 06 5/100% AARP GR08 10/100% AARP GR08 15/250A AARP GR08 20/100% NON-AARP GR08 10-20/250A NAT'L GR 06 10-20/250A NAT'L GR 06 15 BO HRLY-F NO-AARP GR08 15 BO SCPEA NO-AARP GR08 10-20/250A NAT'L-GR06 10-20/500A NAT'L GR 06 10-20/500A NAT'L GR 06 10-20/500A NAT'L GR 06 15/250A NAT'L GR 06 15/250A NAT'L GR 06 15/250A NAT'L GR 06 15-25/500A NAT'L GR 06 15-25/500A NAT'L GR 06 15-25/500A NAT'L GR 06 10-20/250A NON-AARP GR08 14 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit OLV OP3 OP4 OP5 OR1 OR3 OR5 ORX OTZ OVW OY8 OYY PAA PAB PAD PAE PAF PAG PAH PAK PCE PCG PCN PCS PDE PDS PEE PEG PEN PES PIE PIF PIG PIH PII PIK PIL PIN PIO PLP PTD PTG PTM PTS PXY PYD PYG PYI PYN PYS Plan / Benefit Description 5/100% NON-AARP GR08 20-40/250A NAT'L GR 06 20-40/250A NAT'L GR 06 20-40/250A NAT'L GR 06 20/100% NAT'L GR 06 20/100% NAT'L GR 06 20/100% NAT'L GR 06 OTHR RX-NOT PS GR06 20-40/250A AARP GR08 10/100% NON-AARP GR08 10-20/250A NON-AARP GR08 15/250A NON-AARP GR08 PPO - PFFS PPO - PFFS PPO - PFFS PPO - PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS 10/30 PIMA C SH06 EPO 10/30 PIMA C SH06 GOLD 10/30 PIMA C SH06 10/30 PIMA C SH06 SLVR O/3V 1YR POD SH07 O/3V 1YR POD SH07 5/10 PIMA CE SH06 EPO 5/10 PIMA CE SH06 GOLD 5/10 PIMA CE SH06 5/10 PIMA CE SH06 SLVR RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS PAYMENT LAG PREMIUM ALLOC MCC 2 PIMA DELUXE SH07 MCC 2 PIMA GOLD SH07 MC COMP 2 PIMA SH07 MCC 2 PIMA SILVER SH07 $30/Q PHB CREDIT SH08 MCC 1 PIMA DELUXE SH07 MCC 1 PIMA GOLD SH07 RESERVED PFFS MC COMP 1 PIMA SH07 MCC 1 PIMA SILVER SH07 15 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit RE1 RPE RPX S25 S2A S2B S2C S2D S2E S2F S2G S2H S2J S2K S2M S2N S2P S2R S2S S2T S34 S3B S3C S3D S3E S3F S3G S3H S3P S3R S3W S8B SA2 SA3 SAA SBA SGA SNA SP2 SP3 SPA SSP SSR TA6 TAA TAX TPH TPJ TPL TPT Plan / Benefit Description OP REHAB SH-05 RESPITE/PERS CARE SH07 RESPITE/PERS CARE WL-SH08 10-20/250A NON-AARP GR08 0/100% BOEING-GR05 10/100% ADOA-GR05 5/100% NAT'L-GR05 10/100% NAT'L-GR05 10-20/250A NAT'L-GR05 10-20/500A NAT'L-GR05 15/250A NAT'L-GR05 15-25/500A NAT'L-GR05 15-20/100A TOWERS PER-GR05 10/100% BOEING HRLY-GR05 15/100% BOEING HRLY-F-GR05 0/100% BOEING IAM-GR05 20-40/250A NAT'L-GR05 20/100% NAT'L-GR05 15/200A BOEING 148-GR05 10-20/100% ASRS-GR05 10-20/250A AARP GR08 10/100% ADOA-GR06 5/100% NAT'L-GR06 10/100% NAT'L-GR06 10-20/250A NAT'L-GR06 10-20/500A NAT'L-GR06 15/250A NAT'L-GR06 15-25/500A NAT'L-GR06 20-40/250A NAT'L-GR06 20/100% NAT'L-GR06 15-25/500A AARP GR08 10/100% ADOA NON-AARP GR08 10-30/300A MAR-W/DS-SH05 10-30/300A MAR-W/DG-SH05 10-30/300A MAR-AJ-SH05 20-30 PART B-SH05 2-5/50A SECURE GOLD-SH05 10-30/300A PINAL-SH05 10-30/300A PIMAW/DS-SH05 10-30/300A PIMAW/DG-SH05 10-30/300A PIMA-SH05 SILVER SNEAKERS SH05 SLV SNEAK/FITNESS BEN GR06 0/24T NON-ER TRANS SH-06 NON-EMERGENCY TRANS SH05 PCAZ PREMIUM TAX 5-10/100% GR06 15-20/100A AARP GR08 15-20/100A GR06 15-20/100A NON-AARP GR08 16 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit TRD TRW V27 V2A V2B V2C V2D V2E V2F V2G V2L V8P V8Q V8R V8S V8T V8U V8V V8W V8X VA4 VA6 VA7 VAA VAB VAC VAD VAZ VB6 VC8 VDA VDF VDK VFP VFQ VG6 VG8 VGP VGQ VJQ VK8 VKP VMQ VN2 VNQ VP6 VPE VPP VQC VQD Plan / Benefit Description 20-30/250A TRW NO-AARP GR8 20-30/250A TRW GR06 SC 20 ELIGIBILITY ONLY 0/75A BOHRLY GR-VN05 ESA 0/250A BO 837 GR-VN05 ESA 0/0 BO 148 GR-VN05 ESA 0/250A GR-VN05 ESA 10/50A ADOA GR-VN05 ESA 0/70A TOWERS GR-VN05 ESA 0/25%D GR-VN05 0/75A BOHRLY-F GR-VN05 ESA 0 REFRAC 1/V YR VN-GR08 5 REFRAC 1/V YR VN-GR08 10 REFRAC 1/V YR VN-GR08 15 REFRAC 1/V YR VN-GR08 20 REFRAC 1/V YR VN-GR08 25 REFRAC 1/V YR VN-GR08 30 REFRAC 1/V YR VN-GR08 35 REFRAC 1/V YR VN-GR08 40 REFRAC 1/V YR VN-GR08 30/70A 2YRS GR-VN07 5/100A 2 YRS SH-VN06 20/130A 1 YR GR-VN07 0/150A SH-VN05 ESA 5/100A SH-VN05 ESA 0/125A GR-VN05 ESA 0/75A GR-VN05 ESA 20/130A 1YR ASRS GR-VN07 25/150A 2 YRS SH-VN06 20/50A ADOA VN-GR08 15/70A GR-VN07 15/125A 2YRS GR-VN07 20/50A ADOA GR-VN07 ESA 0/75A 2YRS VN-GR08 0/125A 2YRS VN-GR08 25/75A VN-GR06 10/50A ADOA VN-GR08 5/75A 2YRS VN-GR08 5/125A 2YRS VN-GR08 10/75A 2YRS VN-GR08 20/130A 1YR ASRS VN-GR08 10/125A 2YRS VN-GR08 15/125A 2YRS VN-GR08 10/75A 2YRS GR-VN07 20/75A 2YRS VN-GR08 ADVANCE WELLNESS SH-WL06 RESERVED PFFS 20/125A 2YRS VN-GR08 15/130A 1YR DLX VN-SH08 30/70A 2YRS VN-SH08 17 of 640 Plan Benefit - AZ State AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ AZ Plan / Benefit VQJ VQM VQP VRR VSK VSQ VSX VU4 VVP VVQ VWP VWQ VXX VZB VZH WAA WB6 WPR WPS WPT WQR WQS WQT WRR WRS WRT XAA Z2P Z2T Z5R Z8P Plan / Benefit Description 5/100A 2YRS VN-SH08 0/100A 2YRS VN-SH08 25/70A 2YRS VN-GR08 10/75A GR-VN07 5/100A 2YRS SH-VN07 30/70A 2YRS SH-VN07 15/130A 1YR DLX SH-VN07 15/130A 1YR DLX GR-VN07 15/75A 2YRS VN-GR08 25/75A 2YRS VN-GR08 25/125A 2YRS VN-GR08 25/70 2YRS VN-GR08 INFO ONLY 0/250A VN GR08 0/0 BO 148 VN-GR08 EDUC-NUTRITION SH05 HLTH EDUC SH-WL06 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 NO RX GR05 10-15/50A T1A NON-AARP GR8 15-25/200D T3A NO-AARP GR8 15-25/130D T2B N0-AARP GR8 10-20/200A T1C NO-AARP GR8 18 of 640 Plan Benefit - CA Cap/Eligibility CP7810 Assigned Plan Benefit Codes & Descriptions State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 001 002 003 004 005 006 007 009 010 012 013 018 022 026 027 028 030 031 035 036 037 038 040 041 042 043 044 045 046 053 064 071 073 0AD 0C1 0C2 0D3 0D4 0D5 0D6 0D7 0DM Plan / Benefit Description HPA - PLAN A HPA - PLAN B HPA - PLAN C HPA - PLAN D HPA - PLAN E HPA - PLAN F HPA - PLAN G HPA - PLAN I HPA - PLAN I2 EFF 1.1.92 HPA - PLAN L HPA - PLAN M HPA - A1 HPA-VISION ONLY HPA - PLAN Z HPA - PLAN Z1 HPA - PLAN Z2 HPA - PLAN L1 HPA - PLAN LB $3G/$5B HPA - PLAN A2/11.1.91-MH HPA - PLAN A3/11.1.91 NOMH HPA - PLAN C1 HPA-PLAN B (PM DUAL OPT.) HPA - PLAN LJ HPA-PLAN D (PM DUAL OPT.) HPA - PLAN SD (SAME AS L) HPA - PLAN BB HPA - PLAN BK HPA - PLAN L $5G/30%B $4G/$6B HPA-PHARMACY ONLY HPA-PHARMACY ONLY HPA ADMINISTRATION FEE HPA COMM RATED UNDER 50 HPA-COMM RATED 50+ CONTRAT HPA-DENTAL PLAN III HPA-DENTAL PLAN IV HPA-DENTAL BLUE SHIELD HPA-PACIFIC UN DENT /D794F HPA-SIERRA DENTAL/D794F HPA-DURABLE MEDICAL EQUIP 19 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 0EM 0F1 0F3 0F4 0F6 0F7 0FP 0HO 0LA 0LL 0P0 0P1 0P2 0P3 0P4 0P5 0P6 0P7 0P8 0P9 0PC 0PE 0PR 0R1 0RX 0S1 0V1 0V2 103 123 150 15Z 1AA 1AB 1AD 1AE 1AL 1BA 1BR 1C1 1C2 1C3 1C4 1C5 1C6 1CC 1CL 1CN 1CR 1CS Plan / Benefit Description HPA-EXTENDED MENTAL HEALTH HPA-FP STANDARD/WITH RX HPA-FP STANDARD/NO RX HPA-FP-NO COPAY/NO RX HPA-FP-RELIGIOUS WAVIER HPA-FP-DUAL OPTION/RX ONLY HPA-FAMILY PLANNING HPA-HOSPICE HPA-LIFE & ADM/D-794F HPA-LIFELINK COVERAGE HPA-$0 HPA-$1 HPA-$2 HPA-$3 HPA-$4 HPA-$5 HPA-$5G/$10B HPA-$5G/30%B HPA-$3G/$5B HPA-$4G/$6B HPA-PCS (OLD PHARMACY) HPA-EXCOBAR PHARMACY (OLD) HPA-PROSTHETICS($2000) HPA-DRUG REHABILITATION O/P PRESCRIP DRUG $0 COPAY HPA-SUB ABUSE DETOX & REHA HPA-MEDICAL EYE SERVICE HPA-MEDICAL EY SERVICE C1 PPO RESERVED FOR PPO RX DUMMY 1500 PLAN 1500 PLAN (COBRA) 7/7 RX 06 10/10 RX 06 ALAMEDA I STANDARD PLAN ALAMEDA I STANDARD PLAN SH ALAMEDA BASIC W/ NO DEN SANTA BARBARA STANDARD PLN SANTA BARBARA STANDARD PLN $5 $5 $5 $5 $5G/$5B CUSTOM RX $2 COAST CMNTY SH C COSTA BASIC W/ NO DEN SANTA CLARA STANDARD PLAN CONTRA COSTA STANDARD PLAN CONTRA COSTA I STD PLAN CONTRA COSTA I STD PLAN 20 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 1DE 1DG 1DN 1DO 1DS 1DV 1EG 1EO 1EV 1FC 1FE 1FN 1FP 1FR 1FS 1GE 1GG 1GL 1GM 1GO 1JH 1KA 1KE 1KK 1KN 1LA 1LC 1LD 1LE 1LG 1LN 1LO 1LU 1MA 1MC 1MD 1ME 1MG 1MO 1MR 1MT 1NA 1ND 1NE 1NM 1NR 1NV 1OC 1OE 1OG Plan / Benefit Description RIVERSIDE STANDARD PLAN SAN DIEGO I STANDARD PLAN SAN BERNARDINO STD PLAN SAN BERNARDINO STD PLAN RIVERSIDE STANDARD PLAN SAN DIEGO VALUE STD PLAN SAN DIEGO I STANDARD PLAN SAN MATEO STANDARD PLAN VENTURA STANDARD PLAN SAN FRANCISCO CLASSIC I S FRANCSCO CLSC I W/EPODDS FRESNO STANDARD PLAN S FRANCSCO CLSC I W/ODPDDS FRESNO STANDARD PLAN FRESNO STANDARD PLAN ORANGE I STANDARD PLAN 10/20 RX06 LOS ANGELES I STD PLAN 5/5 RX 06 SAN DIEGO I STANDARD PLAN 10/10 RX 06 KERN STANDARD PLAN KERN STANDARD PLAN KERN STANDARD PLAN SH KERN BASIC W/ NO DENTAL SH LA BASIC W/ NO DENTAL 7 LACERA RX05 LOS ANGELES CLASSIC I LOS ANGELES I STD PLAN LOS ANGELES I STD PLAN LOS ANGELES I STD PLAN SAN LUIS OBISPO STANDARD SAN LUIS OBISPO STANDARD MADERA STANDARD PLAN MMC TPA SV $10 PLAN MADERA STANDARD PLAN ALAMEDA I STANDARD PLAN $5G/$5B SAN MATEO STANDARD PLAN MADERA STANDARD PLAN SACRAMENTO I STANDARD PLAN SAN FRANCISCO STANDARD PLN SAN BERNARDINO STD PLAN NEVADA STANDARD PLAN SONOMA STANDARD PLAN SAN BERNARDINO STD PLAN NEVADA STANDARD PLAN SH ORANGE BASIC W/ NO DENT ORANGE I STANDARD PLAN ORANGE STANDARD PLAN 21 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 1PA 1PB 1PL 1PO 1PR 1RA 1RB 1RC 1RD 1RE 1RF 1RG 1RI 1RN 1RR 1RS 1RV 1S1 1SA 1SB 1SC 1SD 1SE 1SF 1SH 1SJ 1SK 1SL 1SM 1SN 1SP 1SS 1SU 1SZ 1TA 1TC 1TO 1TU 1U5 1U7 1UA 1UD 1US 1UZ 1VE 1VR 1VT 1YC 1ZU 200 Plan / Benefit Description PLACER I STANDARD PLAN $5 FLAT PBGH PLACER STANDARD PLAN SAN LUIS OBISPO STANDARD PLACER I STANDARD PLAN $5G/5B $5G/5B 50I $5G/5B HI $5G/5B $5G/5B 50I $5G/5B HI ORANGE STANDARD PLAN RIVERSIDE STANDARD PLAN KERN STANDARD PLAN SANTA BARBARA STANDARD PLN SH RIVERSIDE BAS W/ NO DEN RIVERSIDE STANDARD PLAN $5 SH SACRAM BASIC W/ NO DENT SANTA BARBARA STANDARD SH S CLARA BAS W/ NO DENTA SH S DIEGO BAS W/ NO DENTA SH S BERNARD BAS W/ NO DEN SH S FRAN BASIC W/ NO DENT SACRAMENTO STANDARD PLAN SAN BERNARDINO STANDARD SANTA CLARA STANDARD PLAN SAN LUIS OBISPO STANDARD SAN MATEO STANDARD PLAN STANISLAUS STANDARD PLAN SAN DIEGO STANDARD I PLAN STANISLAUS STANDARD PLAN SANTA CRUZ STANDARD PLAN NOT USED SANTA CLARA STANDARD PLAN 5/5 RX 06 SACRAMENTO I STANDARD PLAN VENTURA STANDARD PLAN $5 RX CODE RESRVD INACTIVATED $10 $10 STANISLAUS STANDARD PLAN SANTA CRUZ STANDARD PLAN VENTURA STANDARD PLAN VENTURA STANDARD PLAN SH VENTURA BAS W/ NO DENTA YOLO STANDARD PLAN SANTA CRUZ STANDARD PLAN MANDATED OFFER RIDERS 22 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 201 202 203 204 205 206 207 208 209 20C 20S 210 211 212 213 214 215 216 217 218 219 21C 21S 220 221 222 223 224 225 226 227 228 229 22C 22D 22R 22S 230 23C 24C 25F 26S 2A2 2A3 2A7 2AA 2AC 2AD 2AF 2AL Plan / Benefit Description ICUPUNCTURE PPO SPECIALIZED FOOTWEAR PPO INFERTILITY PPO ORTHOTIC PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDERS PPO MANDATED OFFER RIDERS PPO MANDATED OFFER RIDERS PPO MANDATED OFFER RIDERS PPO $5G/$10B HERSHEY $10G/$35B MANDATED OFFER RIDERS PPO MANDATED OFFER RIDERS PPO MANDATED OFFER RIDERS PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO $5G/$5B + DIFF $20/$35 $100 DED MANDATED OFFER RIDERS PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO $5G/$10B $5G/$10B MGM 10/20 RX06 $10G/$35B 100I MANDATED OFFER RIDER PPO $15G/$30B/$50NF $5/$15/$35 PBGH 5/5 RX06 15/30 RX 05 ALAMEDA II STANDARD PLAN 10/35 ARADIANT 5/10 RX05 5/5 GGUSD RX05 $10G/$20B FEDS $2G/$2B $15G/$35B/$50NF 2/2 CCC RX05 23 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 2AM 2AN 2AP 2AR 2AS 2AT 2AW 2AY 2B2 2B3 2BA 2BB 2BC 2BE 2BF 2BJ 2BL 2BR 2C0 2C1 2C2 2C3 2C4 2C5 2C6 2C7 2C8 2C9 2CA 2CB 2CC 2CD 2CE 2CF 2CG 2CH 2CI 2CJ 2CK 2CL 2CM 2CN 2CO 2CP 2CQ 2CR 2CS 2CT 2CU 2CV Plan / Benefit Description SH ALAMEDA STANDARD PLAN 4/20/40 LO GR-RX07 $10G/$30B $20G/35B D-I OK TO USE $5G/$15B AT&T $10G/$20B 4/25/50 HI GR-RX07 $5G/$5B $5G/$15B 10/20 RX 06 5/5 RX06 $7G/$7B SH BUTTE STANDARD MED PLAN 7/7 RX07 $5G/$10B 10/25/50 RX-GR08 $20G/35B DHI $10G/$20B CSTM RX $10G/$20B $5G/$10B $10G/$15B $10G/$15B $5G/$15B $10G/$15B $10G/$20B $4G/$7B $7G/$9B $5G/$10B $5G/$10B $5G/$10B $5G/$10B $3G/$5B $10G/$20B $5 CALPERS 2000 $7.50G/$15B $10G/$20B $5G/$15B+DIFF FEDS RX 2001 $5G/$10B $5G/$5B $3G/$5B MO X'S 2 $5G/$10B CUSTOM RX $10G/$15B CUSTOM RX $5G/$15B-$10G/$30B M/O $10G/$15B-$20G/$30B M/O $7G/$7B $5G/$15B SH CONTRA COSTA STANDARD $10G/$20B $5G/$5B 24 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 2CW 2CX 2CY 2CZ 2D2 2DA 2DB 2DC 2DE 2DF 2DL 2DR 2E2 2EA 2EC 2ED 2EP 2ER 2EW 2FC 2FH 2FI 2FL 2FN 2FR 2G1 2G2 2G3 2GA 2GC 2GF 2GG 2GH 2GL 2GM 2GN 2GR 2GX 2HA 2HC 2HD 2HE 2HH 2HM 2HR 2IM 2JD 2JH 2KB 2KH Plan / Benefit Description $7G/$15B $5G/$15B $10G/$15B $5G/$20B ALAMEDA II STANDARD PLAN 7/15 RX 06 5/5 RX 06 $10G/$20B 5/10 RX 06 $10/$30 SDUF $5G/$10B $10G/10B 50I LOS ANGELES II STD PLAN 10/25 RX06 5/15 RX06 SH EL DORADO STANDARD PLAN L. ANGLES CLSCII W/EPO DDS $10G/10B 100I 10/20 RX 06 10/20 SKYWEST 4/15/30 RX-GR08 10/30 FARMERS INS 5/20/45 RX-GR08 SH FRESNO STANDARD PLAN $20G/30B 50I RESERVED INACTIVATED RESERVED INACTIVATED RESERVED INACTIVATED 10/20 RX06 $10G/$20B 5/10 RX 07 5/5 RX06 4/20/40 RX-GR08 7/20 RX 06 $5G/$10B 5/10 RX 06 $20G/30B 100I 7/20 GM 5/10 RX 08 15/30 SARES-REGIS L. ANGELES CLSC II W/HIDDS $15G/$30B 4/15/30 RX-GR08 10/20 RX06 $10G/20B 50I SH IMPERIAL STANDARD PLAN 5/5 RX06 4/20/40 RX-GR08 10/10 RX 07 4/25/50 RX-GR08 25 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 2KR 2KU 2L2 2L6 2L7 2LA 2LC 2LD 2LG 2LH 2LO 2LR 2LS 2LT 2LU 2M2 2MA 2MB 2MC 2MD 2MF 2MH 2MN 2MW 2N2 2NA 2NB 2NH 2ON 2OR 2P2 2PA 2PB 2PG 2PH 2PL 2PR 2PW 2PX 2PY 2PZ 2QA 2QB 2QD 2QH 2R1 2R2 2RA 2RB 2RC Plan / Benefit Description SH KERN STANDARD MED PLAN 10/20 RX06 LOS ANGELES STD. II PLAN 5/5 RX06 5/10 RX06 5/10 CNTY LA 10/30 LA MACHINI L. ANGLES CLSC II W/OP DDS LOS ANGELES CLASSIC II 2/2 RX07 RESERVED $15G/30B 50I SH LOS ANGELES STANDARD 7/9 RX05 3/3 RX06 SACRAMENTO II STD PLAN SH MADERA STANDARD PLAN 10/20 RX 08 MMC TPA SV $15 PLAN 10/25 RX06 5/5 RX07 4/25/45 RX-GR08 SH MARIN STANDARD MED PLAN 15/35 RX06 ORANGE II STANDARD PLAN SH NAPA STANDARD MED PLAN 15/35 RX 07 4/28/55 RX-GR08 OUT-OF-NETWORK SB1221 SH ORANGE STANDARD PLAN PLACER II STANDARD PLAN 5/10 RX 08 PBGH $20 GRP RET PLAN 10/30 RX07 4/28/58 RX-GR08 SH PLACER STANDARD MED 5/10 SP-RX05 10/30 APW 10/35 SP-RX05 10/10 RX05 10/20 RX05 15/30 RX 08 10/35 RX 08 10/25 RX 07 4/25/50 RX-GR08 $10G/$35B CONTRA COSTA II STD PLAN $5G/10B $5G/$10B 50I $5G/10B HI 26 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 2RD 2RE 2RF 2RG 2RH 2RI 2RJ 2RK 2RL 2RM 2RN 2RO 2RP 2RQ 2RR 2RS 2RT 2RU 2RV 2RW 2RX 2RY 2RZ 2S0 2S1 2S2 2S3 2S4 2S5 2S6 2S7 2S8 2S9 2SA 2SB 2SC 2SD 2SE 2SF 2SG 2SH 2SI 2SJ 2SL 2SM 2SN 2SO 2SQ 2SR 2SS Plan / Benefit Description $5G/15B $5G/15B 50I $5G/15B HI $10G/15B $10G/15B 50I $10G/15B HI $10G/20B $10G/20B 50I $10G/20B HI $10G/25B $10G/25B 50I $10G/25B HI $10G/35B $10G/35B 50I SH RIVERSIDE STANDARD PLAN $10G/35B HI $15G/25B $15G/25B 50I $15G/25B HI $15G/35B $15G/35B 50I $15G/35B HI $20G/35B D $7G/$9B $10G/$15B $10G/$30B $10G/$15B $10G/$15B $10G/$25B $5G/$10B $4(FLAT) $10G/$30B PPO MID/LARGE $10G/$25B $20G/$35B SH SAN BERNARDINO STANDARD $10G/$30B $10G/$25B $20G/$35B $10G/$30B SH SAN DIEGO STANDARD PLAN $10G/$10B RESERVED $10G/$10B SH SAN LUIS OBISPO STD MED SH SACRAMENTO STANDARD MED SH SAN FRANCISCO STD MED RESERVED SH SAN JOAQUIN STANADARD SH SANTA BARBARA STD MED SH STANISLAUS STANDARD MED 27 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 2ST 2SV 2SW 2SX 2SY 2SZ 2T2 2TA 2TC 2TE 2TH 2U1 2U2 2U3 2U4 2U5 2U6 2UA 2UB 2UC 2UD 2UE 2UF 2UG 2UH 2UK 2VB 2VH 2VN 2WD 2WH 2WP 2XA 2XH 2YH 2ZA 2ZB 2ZC 2ZD 2ZE 2ZF 2ZG 30C 30N 313 31S 32C 32S 33C 33R Plan / Benefit Description SH SAN MATEO STANDARD MED 5/10 RX06 SH SONOMA STANDARD MED SH SANTA CLARA STANDARD SH SOLANO STANDARD MEDICAL SH SANTA CRUZ STANDARD MED CONTRA COSTA II STD PLAN 5/20 RX 08 5/5/25 RX07 SH TULARE STANDARD MEDICAL 20/35 100D RX 06 $5G/$10B $5G/$15B $5G/$20B RX CODE RESRVD INACTIVATED $10G/$20B $10G/$25B $5G/$10B $5G/$15B RX CODE RESERVED INACTIVAT RX CODE RERRVD INACTIVATED $10G/$20B RX CODE RESRVD INACTIVATED 20/40 RX06 10/25/50 RX-GR08 10/20 RX06 0/5 RX 07 10/25/50 RX-GR08 SH VENTURA STD-I LOW PLAN L. ANGELES CLSC I W/OP DDS 5/20/45 RX-GR08 5/5 RX06 7/7 RX07 5/20/45 RX-GR08 4/10/20 RX-GR08 0/0 GR-RX07 2/40 GR-RX07 5/25 GR-RX07 5/65 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 10/20 RX06 10/20/35 HCA LP OUT-OF-NETWORK SB1221 IND RESERVED FOR PREMIER PASS $10G/$25B/$50NF $10G/$20B/$30NF 10G/25B/35NF 150I $10/15/25 BURNHAM 5/10/20 SSCA RX05 28 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 33S 33T 34S 35S 36C 39C 3A3 3A6 3AA 3AC 3AL 3AM 3AP 3AR 3AS 3AU 3AV 3B2 3B3 3B4 3B6 3BA 3BB 3BC 3BD 3BE 3BF 3BH 3BL 3BN 3BO 3BP 3BR 3BS 3BT 3BU 3BV 3C0 3C1 3C2 3C3 3C4 3C5 3C6 3C7 3C8 3C9 3CA 3CB 3CC Plan / Benefit Description 10G/25B/50NF 0I 5/10/20 RX06 15G/35B/50NF 150I 15/35/50 RX05 5/15/30 RX06 5/15/30 RX06 LOS ANGELES VALUE STD PLAN 20/30/50 RX06 10/20/35 RX06 10/20/35 RX06 ALAM PT B BASIC W/ NO DENT SH ALAMEDA BASIC MED PLAN 10/20/25 AMYLIN $10G/25B/50NF 10/20/35 C SCHWAB 5/20/35 RX 06 10/20/50 AVON $5G/$15B/$30NF 5/15/30 SNBRD RX05 5G/15B/30NF GRP RT 5/15/25 RX06 20/35/50 RX 07 5/10/15 RX 07 $10G/$20B/$35NF 10/20/30 ABCW RX05 SH BUTTE BASIC MED PLAN 10/20/40 RX07 $15G/$30B $5G/$15B/$30NF $5G/$15B/$30NF $5G/$15B/$30NF $5G/$15B/$35NF $10G/25B/50NF 50I $20G/$35B/$50NF $10G/$20B/$35NF 10/20/45 RX 05 $10G/$20B/$35NF $10/$25/$50 ADMINSTAFF $5/$10/$25 $8/$8/$20 $10G/$15B/$25NF $10G/$15B/$25NF $5G/$10B/$20NF $7G/$15B/$35NF $7G/$15B/$35NF $7G/$15B/$35NF $10G/$20B/$40NF $5/$10/$25 500 SERIES $5G/$15B/$30NF C COSTA PT B BAS W/ NO DEN 29 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 3CD 3CE 3CF 3CG 3CH 3CI 3CJ 3CK 3CL 3CM 3CN 3CO 3CQ 3CR 3CS 3CT 3CU 3CV 3CW 3CX 3CY 3D3 3DA 3DB 3DC 3DD 3DF 3DI 3DQ 3DR 3DU 3DZ 3E4 3E5 3E6 3E7 3E9 3EA 3EC 3ED 3EG 3EL 3ER 3ES 3ET 3EU 3FB 3FC 3FD 3FH Plan / Benefit Description $5G/$5B/$20NF $10G/$15B/$30NF CUSTOM RX $10G/$15B/$25NF $10G/$20B/$35NF $5G/$15B/$30NF $10G/$20B/$25NF $10G/$10B/$20NF $10G/$25B/$50NF 10/20/25 AM RED CS 10/20/35 GR-RX05 $5G/$10B/$15NF $10G/$20B/$35NF 5/15/25 CRC RX05 $10G/25B/50NF HI $5G/$20B/$35NF SH CONTRA COSTA BASIC MED $5G/$5B/$20NF $5G/$10B/$20NF $15G/$30B/$50NF 10G/20B/40NF PEPSI 10G/20B/35NF VEBA SAN DIEGO III STD PLAN 10/25/35 RX 05 15/35/50 RX 05 10/20/40 DUDEK 5/20/40 RX 08 5/10/20 RX 07 SAN DIEGO III STD PLAN 5/15/35 RX 08 $15G/25B/40NF 5/20/50 RX 06 5/10/25 RX 06 10/25/35 RX06 10/25/35 RX06 10/25/35 RX06 10/25/35 RX06 10/25/35 RX06 3 VISIT EAP /INCIDENT 10/20/35 GOODRICH SH EL DORADO BASIC MEDICAL SAN DIEGO CLASSIC III $10G/$20B/$35NF $15G/25B/40NF 50I 10/15/25 SEMPRA 5/15/30 L3ET RX05 5/15/30 RX06 10/20/40 RX 07 10/30/50 RX05 15/30/60 RX06 10/20/25 CFHC RX05 30 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 3FL 3FN 3FR 3FS 3G1 3G2 3G3 3G4 3G5 3GA 3GB 3GC 3GD 3GE 3GS 3GU 3GV 3HA 3HB 3HC 3HD 3HE 3HP 3HS 3HU 3IC 3IM 3JA 3JG 3JP 3JU 3KA 3KC 3KG 3KN 3KR 3KV 3L0 3L1 3L2 3L3 3L4 3L5 3L6 3L7 3L8 3L9 3LA 3LB 3LC Plan / Benefit Description 15/30/45 RX 06 SH FRESNO BASIC MED PLAN $15G/25B/40NF HI 10/30/40 5STR RX05 INACTIVATED RESERVED INACTIVATED RESERVED INACTIVATED $5G/$10B/$25NF $10G/$20B/$35NF $15G/$25B/$40NF 15G/25B/40NF W/INJ $10G/$20B/$35NF 15/25/40 GOODRICH 10/25/35 RX06 7/20/30 GM SAL 5/15/30 RX06 15/35/50 RX06 5/30/45 RX 06 5/10/15 RX 07 $5G/$25B/$40NF HP L.ANGLES CLSC I W/HIOP DDS 5/10/25 RX 07 5/30/45 GRRX07 5/10/25 RX 07 $10G/$20B/$35NF 06 10/25/35 FOLEY SH IMPERIAL BASIC MED PLAN 10/20/35 RX 07 5/5/20 RX06 10G/25B/40NF JPM $5G/$10B/$35NF 06 5/15/25 RX 07 10/20/25 SCC RX05 5/10/25 RX 07 SH KERN PT B BAS W/ NO DEN SH KERN BASIC MEDICAL PLAN 5/20/40 RX 08 E $15G/30B/50NF D 10/20/45E 10G/20B/45NF 50I E 10G/20B/45N 100I E 10/30/50E 10G/30B/50NF 50I E 10G/30B/50N 100I E 15/25/50E 15G/25B/50NF 50I E 15G/25B/50N 100I E SH LA PT B BASIC W/ NO DEN 15/30/50 D 50I E 15/30/50 D 100I E 31 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 3LD 3LE 3LF 3LL 3LO 3LS 3LU 3LV 3M2 3M3 3M4 3M5 3M6 3M7 3M8 3M9 3MA 3MB 3MC 3ME 3MG 3MI 3ML 3MN 3MP 3MS 3N3 3NA 3NC 3ND 3OC 3OE 3OK 3ON 3OR 3P2 3PA 3PC 3PF 3PG 3PH 3PL 3PP 3PQ 3PR 3PS 3PT 3PV 3PW 3PX Plan / Benefit Description 5/10/20 RX06 5/15/30 RX06 10/20/35 RX06 10/20/50 GR-RX07 RESERVED SH LOS ANGELES BASIC MED 5/10/35 RX 06 LOS ANGELES VALUE STD PLAN $5G/15B/30NF 50I $20G/30B/50NF 50I $15G/30B/45NF 50I $20G/30B/50NF 100I $5G/15B/30NF 100I $15G/30B/45NF 100I $20G/35B/50NF D-I $20G/35B/50NF DHI SH MADERA BASIC MED PLAN 10/20/45 RX07 MMC TPA SV $35 PLAN 15/30/55 RX07 5/10/25 RX 07 10/20/35 MARRIOTT 10/20/35 MER LYN SH MARIN BASIC MED PLAN 5/10/20 MPAN RX05 20/35/50 MSSY RX05 SAN DIEGO STD. III PLAN SH NAPA BASIC MED PLAN 10/20/35 RX06 10/20/25 SND RX05 ORANGE PT B BASIC W/ NO DE 10/20/35 OPER ENG 5/15/25/25 GR-RX07 INDIVIDUAL POS OON-SB1221 SH ORANGE BASIC MED PLAN 10/20/25 PERKOWITZ $10G/$25B/$50NF E $10G/$30B/$40NF E 10/25/40 RX06 10/25/45 RX 06 10/30/50 RX06 SH PLACER BASIC MED PLAN 5/15/40 RX05 10/20/35 RX 06 10/20/35 PEARSON INC $5G/$15B/$30NF GRP RET RESERVED 3TIER RX06 5/15/45 RX05 10/20/30 RX05 10/30/50 1SDS RX05 32 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 3PY 3PZ 3QB 3QD 3QE 3R1 3R5 3R6 3RA 3RB 3RC 3RD 3RE 3RF 3RG 3RH 3RI 3RJ 3RK 3RL 3RM 3RN 3RO 3RP 3RQ 3RR 3RS 3RT 3RU 3RV 3RW 3RX 3RY 3RZ 3S1 3S2 3S3 3S4 3S5 3S6 3S7 3S8 3S9 3SA 3SB 3SC 3SD 3SE 3SF 3SG Plan / Benefit Description 10/20/25 SP-RX05 10/25/35 SP-RX05 5/15/25 RX 07 10/25/35 QUIDEL 10/20/40 RX07 $10G/$25B/$35NF 10/20/30 RIVERSIDE 10/30/50 RX06 $5G/10B/20NF $5G/10B/20NF 50I $5G/10B/20NF HI $5G/10B/25NF $5G/10B/25NF 50I $5G/10B/25NF HI $5G/15B/25NF $5G/15B/25NF 50I $5G/15B/25NF HI $10G/20B/25NF $10G/20B/25NF 50I $10G/20B/25NF HI $10G/20B/30NF $10G/20B/30NF 50I $10G/20B/30NF HI $10G/20B/40NF $10G/20B/40NF 50I SH RIVERSIDE BASIC MED PLN SH RIVER PT B BAS W/ NO DE $10G/20B/40NF HI $10G/25B/35NF $10G/25B/35NF 50I $10G/25B/35NF HI $10G/25B/40NF $10G/25B/40NF 50I $10G/25B/40NF HI $5/$5/$20 $10/$10/$20 $5/$15/$25 $5/$10/$20 $10/$10/$20 $10G/$20B/$25NF EL $10G/20B/25NF PR $10G/25B/35NF $15G/$35B/$50NF SACRAM PT B BAS W/ NO DENT SH SAN BERNARDINO BASIC S CLARA PT B BAS W/ NO DEN S DIEGO PT B BAS W/ NO DEN S BERNARD PT B BAS W/ NO D S FRAN PT B BAS W/ NO DENT SH SAN DIEGO BASIC MED 33 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 3SH 3SI 3SJ 3SK 3SL 3SM 3SN 3SO 3SQ 3SR 3SS 3ST 3SW 3SX 3SY 3SZ 3T6 3TA 3TE 3TG 3TM 3TT 3TU 3U1 3U2 3U3 3U4 3U6 3U7 3U8 3U9 3UA 3UB 3UC 3UD 3UE 3UF 3UG 3UH 3UI 3UJ 3UK 3UL 3UN 3UP 3UV 3V3 3V4 3V5 3V6 Plan / Benefit Description 10/20/35 RX06 RESERVED 10/20/35 RX06 10/20/35 RX 06 SH SAN LUIS OBISPO BASIC SH SACRAMENTO BASIC MED SH SAN FRANCISCO BASIC MED RESERVED SH SAN JOAQUIN BASIC MED SH SAN BARBARA BASIC MED SH STANISLAUS BASIC MED SH SAN MATEO BASIC MED SH SONOMA BASIC MED PLAN SH SANTA CLARA BASIC MED SH SOLANO BASIC MED PLAN SH SANTA CRUZ BASIC MED 10/20/35 RX06 10/30/50 RX-06 SH TULARE BASIC MED PLAN 10/20/35 RX 06 $5G/$10B/$35NF 5/10/35 RX 05 $10G/$25B/$35NF 06 $5/$10/$20 $10/$10/$25 RX CODE RESERVED INACTIV RX CODE RESRVD INACTIVATED RX CODE RESRVED INACTIVATE RX CODE RESRVD INACTIVATED RX CODE RESRVD INACTIVATED RX CODE RESRVD INACTIVATED $5/$10/$20 RX CODE RESRVD INACTIVATED 10/20/35 UC RX05 RX CODE RESRVD INACTIVATED RX CODE RESRVD INACTIVATED RX CODE RESRVD INACTIVATED $5/$15/$30 RX CODE RESRVD INACTIVATED $10/$20/$35 $10G/$15B/$25NF $5/$15/$30 PUB SEC $5/$15/$45 PUB SEC 10/20/35 RX 06 10/20/30 RX 06 RESERVED 3TIER RX LOS ANGELES VALUE STD PLAN 15/35/50 RX06 15/35/50 RX06 15/35/50 RX06 34 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 3V7 3V9 3VA 3VB 3VC 3VF 3VN 3VT 3WA 3WD 3WE 3WG 3WH 3XH 3XK 3YB 3YF 3ZA 3ZB 3ZC 3ZD 3ZE 3ZF 3ZG 3ZH 3ZJ 3ZK 3ZL 3ZM 3ZR 3ZT 40A 40B 40C 40D 40E 40F 40G 40H 40I 40J 40K 40L 40M 40N 40O 40P 40Q 40R 40S Plan / Benefit Description 15/35/50 RX06 15/35/50 RX06 CODE IS FOR OR RX BENEFIT 10/20/35 RX 08 5/10/20 RX 07 10/20/35 RX 08 SH VENTURA BASIC MED PLAN VENT PT B BASIC W/ NO DENT 10/20/35 RX 05 S DIEGO CLSC III W/OP DDS S DIEGO CLSC III W/EPO DDS 5/10/25 RX 07 S DIEGO CLSC III W/HI DDS 5/10/25 RX 07 10/25/35 RX06 10/30/45 RX 07 5/15/30 RX 08 5/15/30 SCEET RX05 5/10/35 SCEET RX05 5/10/25 RX05 10/20/25 RX05 5/10/20 GR-RX07 10/20/35 GR-RX07 10/20/35 GR-RX07 10/25/55 GR-RX07 10/40/75 GR-RX07 7/20/50% GR-RX07 2/30/60 GR-RX07 10/25/50 GR-RX07 20/35/50 RX06 10/25/50 RX06 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 35 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 40T 40U 40V 40W 40X 40Y 40Z 41A 41B 41C 41D 41E 41F 41G 41H 41I 41J 41K 41L 41M 41N 41O 41P 41Q 41R 41S 41T 41U 41V 41W 41X 41Y 41Z 42I 43A 43I 43J 43K 440 44A 44I 44N 44P 45I 45J 45K 46I 46J 46K 47I Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO MCC 1 S DIEGO GR08 RESERVED RX PPO MCC 1 S BERDO GR08 MCC 1 S BERDO DLX GR08 RESERVED RX PPO MCC S FRAN GR08 RESERVED RX PPO MCC 1 FRSNO GR08 MCC 1 MADRA GR08 RESERVED RX PPO MCC S JOAQUIN GR08 MCC S JOAQUIN DLX GR08 RESERVED RX PPO MCC KERN GR08 MCC KERN DLX GR08 RESERVED RX PPO 36 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 47J 47K 48I 48R 48S 49I 49R 49S 4A0 4A1 4A2 4A3 4AA 4AD 4AE 4AI 4AM 4AO 4B0 4B1 4BE 4BH 4BI 4BL 4BO 4BW 4C0 4C1 4C2 4C3 4C4 4CF 4CI 4CL 4CO 4CT 4D0 4D1 4D2 4D3 4DE 4DG 4DI 4DN 4DO 4DS 4DV 4E0 4E1 4E2 Plan / Benefit Description MCC 1 RVSIDE GR08 MCC 1 RVSIDE DLX GR08 RESERVED RX PPO MCC 1 LA GR08 MCC 1 LA DLX GR08 RESERVED RX PPO MCC 1 OR GR08 MCC 1 OR DLX GR08 RESERVED RX PPO RESERVED RX PPO ALAMEDA II PLUS PLAN LOS ANGLES VALUE PLUS PLAN MEDCO CARVE OUT A RX05 ALAMEDA I PLUS PLAN ALAMEDA I PLUS PLAN RESERVED RX PPO RESERVED RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED ARP MCC 1 ALMDA HI SH08 RESERVED RX PPO ARP MCC 1 ALMDA LO SH08 RESERVED RX PPO ARP MCC 1 ALMDA SH08 RESERVED RX PPO RESERVED RX PPO $7G/$15B/$35NF $5G/$10B/$25NF DCHS $5G/$10B/$25NF CHW $5G/$10B RESERVED RX PPO SANTA CLARA PLUS PLAN RESERVED RX PPO RESERVED RESERVED RX PPO RESERVED RX PPO ALAMEDA II PLUS PLAN SAN DIEGO III PLUS PLAN RIVERSIDE PLUS PLAN SAN DIEGO I PLUS PLAN SAN DIEGO III PLUS PLAN SAN BERNARDINO PLUS PLAN SAN BERNARDINO PLUS PLAN RIVERSIDE PLUS PLAN SAN DIEGO VALUE PLUS PLAN RESERVED RX PPO RESERVED RX PPO LOS ANGELES II PLUS PLAN 37 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 4ED 4EG 4EI 4EO 4EP 4F0 4F1 4FI 4FN 4FO 4G0 4G1 4GE 4GI 4GL 4GO 4H0 4H1 4HD 4HI 4HO 4I0 4I1 4IA 4IB 4IC 4ID 4IE 4IF 4IG 4IH 4II 4IJ 4IK 4IL 4IM 4IN 4IO 4IP 4IQ 4IR 4IS 4IT 4IU 4IV 4IW 4IX 4IY 4IZ 4J0 Plan / Benefit Description RESERVED SAN DIEGO I PLUS PLAN RESERVED RX PPO RESERVED RX PPO L.ANGLES CLSC I W/EPO DDS RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO ORANGE I PLUS PLAN RESERVED RX PPO LOS ANGELES I PLUS PLAN SAN DIEGO I PLUS PLAN RESERVED RX PPO RESERVED RX PPO S MATEO CLSC I W/HI DDS RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 38 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 4J1 4JI 4JO 4K0 4K1 4KI 4KN 4KO 4KR 4L0 4L1 4L2 4LE 4LG 4LI 4LN 4LO 4LV 4M0 4M1 4M2 4MA 4MC 4ME 4MI 4MN 4MO 4MT 4N0 4N1 4N2 4N3 4NA 4ND 4NI 4NO 4NR 4O0 4O1 4OA 4OB 4OC 4OD 4OE 4OF 4OG 4OH 4OI 4OJ 4OK Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO SH KERN STD - PART B ONLY RESERVED RX PPO RESERVED RESERVED RX PPO RESERVED RX PPO LOS ANGELES II PLUS PLAN LOS ANGELES I PLUS PLAN LOS ANGELES I PLUS PLAN RESERVED RX PPO LOS ANGELES I PLUS PLAN RESERVED LOS ANGLES VALUE PLUS PLAN RESERVED RX PPO RESERVED RX PPO SACRAMENTO II PLUS PLAN RESERVED MMC TPA SV $35 PLAN HIPPA ALAMEDA I PLUS PLAN RESERVED RX PPO RESERVED RESERVED RX PPO SACRAMENTO I PLUS PLAN RESERVED RX PPO RESERVED RX PPO ORANGE II PLUS PLAN SAN DIEGO III PLUS PLAN RESERVED SAN BERNARDINO PLUS PLAN RESERVED RX PPO RESERVED RX PPO SAN BERNARDINO PLUS PLAN RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO ORANGE I PLUS PLAN RESERVED RX PPO ORANGE PLUS PLAN RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 39 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 4OL 4OM 4ON 4OO 4OP 4OQ 4OR 4OS 4OT 4OU 4OV 4OW 4OX 4OY 4OZ 4P0 4P1 4PI 4PL 4PO 4Q0 4Q1 4QI 4QO 4R0 4R1 4RG 4RI 4RO 4RR 4RV 4S0 4S1 4SA 4SB 4SC 4SD 4SE 4SG 4SH 4SI 4SJ 4SK 4SL 4SM 4SN 4SO 4SP 4SQ 4SR Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO NATIONAL POS OON SB1221 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO ORANGE PLUS PLAN RIVERSIDE PLUS PLAN RESERVED RX PPO RESERVED RIVERSIDE PLUS PLAN RESERVED RX PPO RESERVED RX PPO KEENAN COMP S CLARA GR07 RESERVED SAN MATEO CLASSIC I S MATEO CLSC I W/OP DDS S MATEO CLSC I W/EPO DDS SH SAN DIEGO STD-II ($0) SACRAMENTO PLUS PLAN RESERVED SAN BERNARDINO PLUS PLAN SANTA CLARA PLUS PLAN RESERVED RESERVED RESERVED RESERVED SAN DIEGO I PLUS PLAN RESERVED RESERVED 40 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 4SS 4ST 4SX 4SY 4SZ 4T0 4T1 4TA 4TE 4TI 4TO 4U0 4U1 4UI 4UO 4V0 4V1 4V3 4VI 4VN 4VO 4W0 4W1 4WI 4WO 4X0 4X1 4X5 4XI 4XO 4XP 4XQ 4XR 4Y0 4Y1 4YI 4YO 4Z0 4Z1 4ZI 4ZO 50A 50B 50C 50D 50E 50F 50G 50H 50I Plan / Benefit Description RESERVED SH SAN MATEO STD/ENDORSED RESERVED RESERVED RESERVED RESERVED RX PPO RESERVED RX PPO SANTA CLARA PLUS PLAN RESERVED RESERVED RX PPO SACRAMENTO I PLUS PLAN RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO LOS ANGLES VALUE PLUS PLAN RESERVED RX PPO RESERVED RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO KEC S CLARA CG GR07 RESERVED RX PPO RESERVED RX PPO 5/29/60 N/G GR-RX7 5/29/60 W/G GR-RX7 5/29/60 N/G 3 GRX7 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 41 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 50J 50K 50L 50M 50N 50O 50P 50Q 50R 50S 50T 50U 50V 50W 50X 50Y 50Z 51A 51B 51C 51D 51E 51F 51G 51H 51I 51J 51K 51L 51M 51N 51O 51P 51Q 51R 51S 51T 51U 51V 51W 51X 51Y 51Z 52I 535 536 537 538 539 53I Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO 42 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 540 541 542 543 544 545 546 547 548 549 54I 550 551 552 553 554 555 556 557 558 559 55I 560 561 562 563 564 565 566 567 568 569 56I 570 571 572 573 574 575 576 577 578 579 57I 580 581 582 583 584 585 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO 43 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 586 587 588 589 58I 590 591 592 593 594 59I 5A0 5A1 5A2 5A3 5AC 5AD 5AE 5AI 5AL 5AM 5AO 5B0 5B1 5B2 5BB 5BE 5BI 5BO 5C0 5C1 5CC 5CD 5CI 5CL 5CN 5CO 5CR 5CS 5CT 5D0 5D1 5D2 5D3 5DD 5DE 5DG 5DI 5DN 5DO Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO ALAMEDA II STD W/OPT DDS L.A. VALUE STD W/OPT DDS PPO ACUPUNTURE TRMNT RIDER ALAMEDA I STD W/OPT DDS ALAMEDA I STD W/OPT DDS RESERVED BENEFIT PPO SH ALAMEDA PLUS W/ NO DENT RESERVED RESERVED BENEFIT PPO RESERVED BENEFIT PPO SH PART B STD W/NO PREMIUM SH PART B STANDARD W/$50 SH PART B - SD, IMP. & VNT RESERVED RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO CONTRA COSTA PLS W/ NO DEN KEENAN COMP S CRUZ GR07 RESERVED BENEFIT PPO SANTA CLARA STD W/OPT DDS CONTRA COSTA STD W/OP DDS RESERVED BENEFIT PPO CNTRA COSTA I STD W/OP DDS CNTRA COSTA I STD W/OP.DDS RESERVED RESERVED BENEFIT PPO RESERVED BENEFIT PPO ALAMEDA II STD W/OPT DDS S.DIEGO III STD W/OP DDS SAN MATEO MEDICAL W/OP DDS RIVERSIDE STD W/OPT DDS SAN DIEGO I STD W/OP DDS S.DIEGO III STD W/OP DDS S.BERNARDINO STD W/OP DDS S.BERNARDINO STD W/OP DDS 44 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 5DP 5DS 5DV 5E0 5E1 5E2 5ED 5EG 5EI 5EO 5EP 5EV 5F0 5F1 5FI 5FN 5FO 5FP 5FT 5G0 5G1 5GE 5GI 5GL 5GO 5H0 5H1 5HA 5HD 5HI 5HO 5I0 5I1 5IA 5IB 5IC 5ID 5IE 5IF 5IG 5IH 5II 5IJ 5IK 5IL 5IM 5IN 5IO 5IP 5IQ Plan / Benefit Description PPO DOMESTIC PARTNER RIDER RIVERSIDE STD W/OPT DDS S.DIEGO VALUE STD W/OP DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO LOS ANGLES II STD W/OP DDS RESERVED SAN DIEGO I STD W/OP DDS RESERVED BENEFIT PPO SAN MATEO STD W/OPT DDS SAN MATEO MEDICL W/EPO DDS VENTURA STANDARD W/OPT DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED RESERVED BENEFIT PPO PPO FAMILY PLANNING RIDER PPO FOOTWEAR RIDER RESERVED BENEFIT PPO RESERVED BENEFIT PPO ORANGE I STD W/OPT DDS RESERVED BENEFIT PPO LOS ANGELES I STD W/OP DDS SAN DIEGO I STD W/OP DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO PPO HEARING AID RIDER SAN MATEO MEDICL W/HI DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 45 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 5IR 5IS 5IT 5IU 5IV 5IW 5IX 5IY 5IZ 5J0 5J1 5JI 5JO 5K0 5K1 5KA 5KE 5KI 5KK 5KN 5KO 5KR 5L0 5L1 5L2 5LA 5LE 5LG 5LI 5LN 5LO 5LV 5M0 5M1 5M2 5MA 5MB 5MC 5ME 5MI 5MM 5MN 5MO 5MT 5N0 5N1 5N2 5N3 5NA 5ND Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO PPO INFERTILITY RIDER RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO KERN STANDARD W/OPT DDS KERN STANDARD W/OPT DDS RESERVED BENEFIT PPO KERN STANDARD W/OPT DDS SH KERN PLUS W/ NO DENTAL RESERVED BENEFIT PPO RESERVED RESERVED BENEFIT PPO RESERVED BENEFIT PPO LOS ANGLES II STD W/OP.DDS SH LA PLUS MED W/ NO DENTA LOS ANGELES I STD W/OP.DDS LOS ANGELES I STD W/OP DDS RESERVED BENEFIT PPO LOS ANGELES I STD W/OP DDS RESERVED L.A. VALUE STD W/OPT DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO SACRAMENTO II STD W/OP DDS RESERVED KEENAN COMP S MATEO GR07 MMC TPA SV $10 PLAN HIPPA ALAMEDA I STD W/OPT DDS RESERVED BENEFIT PPO SAN MATEO STD. W/OPT. DDS RESERVED SAN MATEO STD W/OPT DDS SACRAMENTO I STD W/OP DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO ORANGE II STD W/OPT DDS S. DIEGO III STD. W/OP.DDS RESERVED S.BERNARDINO STD W/OP DDS 46 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 5NI 5NO 5NR 5O0 5O1 5O2 5O3 5O4 5O5 5O6 5O7 5O8 5O9 5OA 5OB 5OC 5OD 5OE 5OF 5OG 5OH 5OI 5OJ 5OK 5OL 5OM 5ON 5OO 5OP 5OQ 5OR 5OS 5OT 5OU 5OV 5OW 5OX 5OY 5OZ 5P0 5P1 5PI 5PL 5PO 5Q0 5Q1 5QI 5QO 5R0 5R2 Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO S.BERNARDINO STD W/OP DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO SH ORANGE PLUS W/ NO DENTA RESERVED BENEFIT PPO ORANGE I STD W/OPT DDS RESERVED BENEFIT PPO ORANGE STANDARD W/OPT. DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO PPO ORTHO/PROSTHETIC RIDER RESERVED BENEFIT PPO RESERVED RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO CNTRA CSTA II STD W/OP DDS 47 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 5RG 5RI 5RN 5RO 5RR 5RS 5RV 5S0 5S5 5SA 5SB 5SC 5SD 5SE 5SF 5SG 5SH 5SI 5SJ 5SK 5SL 5SM 5SN 5SO 5SP 5SQ 5SR 5SS 5ST 5SX 5SY 5SZ 5T0 5T1 5T2 5TA 5TE 5TI 5TM 5TO 5TU 5U0 5U1 5UI 5UO 5V0 5V1 5V3 5VE 5VI Plan / Benefit Description ORANGE STD W/OPT DDS RIVERSIDE STD W/OPT DDS KERN STANDARD W/OPT DDS RESERVED BENEFIT PPO RESERVED SH RIVERSIDE PLS W/ NO DEN RIVERSIDE STD. W/OPT. DDS RESERVED BENEFIT PPO SACRAMENTO STD. W/OPT. DDS SH SACRAM PLUS W/ NO DENTA RESERVED SH S CLARA PLUS W/ NO DENT SH S DIEGO PLUS W/ NO DENT SH S BERNARD PLS W/ NO DEN SH S FRAN PLUS W/ NO DENTA SAN DIEGO-II STD. W/HI DNT PPO SPEECH & HEARING RIDER RESERVED S. BERNARDINO STD W/OP.DDS SANTA CLARA STD W/OPT. DDS RESERVED RESERVED RESERVED RESERVED SAN DIEGO I STD. W/OPT DDS RESERVED RESERVED RESERVED RESERVED RESERVED RESERVED RESERVED RESERVED BENEFIT PPO RESERVED BENEFIT PPO CNTRA CSTA II STD W/OP.DDS SANTA CLARA STD W/OPT DDS RESERVED RESERVED BENEFIT PPO SAN MATEO MEDICAL SACRAMENTO I STD W/OP DDS VENTURA STANDARD W/OPT DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO L.A. VALUE STD W/OPT DDS VENTURA STANDARD W/OPT DDS RESERVED BENEFIT PPO 48 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 5VN 5VO 5VR 5VT 5W0 5W1 5WI 5WO 5X0 5X1 5XI 5XO 5Y0 5Y1 5YI 5YO 5Z0 5Z1 5ZI 5ZO 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 Plan / Benefit Description RESERVED RESERVED BENEFIT PPO PPO 500 SERIES VISION RDR VENTURA STANDARD W/OPT DDS RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 49 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 6A2 6A3 6AA 6AD 6AE 6AH 6AJ 6AL 6AM 6AP 6AY 6BG 6BH 6BL 6BR 6CD 6CH 6CI 6CJ 6CL Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO ALAMEDA II STD W/HI DDS L.A. VALUE STD W/HI OP DDS SV 25-35/300A+75% 06 ALAMEDA I STD W/HI DDS ALAMEDA I STD W/HI OPT DDS 0/0 HI GR-RX07 SV 25-35/300A+75% 06 AB 0/0 LO GR-RX07 SH ALAMEDA PLUS PLAN 8.50/25.90/50% SH6 SV 25-35/300A+75% 06 CB SAN BERNARDINO SECURE GOLD 2/30/60 HI GR-RX07 2/30/60 LO GR-RX07 0/0 FLAT GR-RX06 7/14 GR-RX06 SP 10/100% SD CHRGRS 06 7/14 I GR-RX06 SP 10/100% SD CHRGRS 06 AB SANTA CLARA STD W/HI DDS 50 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 6CN 6CP 6CR 6CS 6CT 6CY 6D2 6D3 6DD 6DE 6DG 6DH 6DI 6DL 6DN 6DO 6DR 6DS 6DV 6E2 6EG 6EH 6EL 6EO 6EV 6FA 6FD 6FH 6FJ 6FL 6FY 6GD 6GE 6GG 6GL 6GO 6GP 6GR 6HH 6HI 6HL 6HP 6HR 6JH 6JL 6JM 6JP 6JR 6KA 6KE Plan / Benefit Description CONTRA COSTA STD W/HI DDS 8.50/26.15/50% SH6 CNTRA COSTA I STD W/HI DDS CNTRA COSTA I STD W/HI DDS SH CONTRA COSTA PLUS PLAN SP 10/100% SD CHRGRS 06 CB ALAMEDA II STD W/HI OP DDS SAN DIEGO III STD W/HI DDS 7/20/30 GR-RX06 RIVERSIDE STD W/HI OP DDS SAN DIEGO I STD W/HI DDS 2/40 HI GR-RX07 SAN DIEGO III STD W/HI DDS 2/40 LO GR-RX07 S.BERNARDINO STD W/HI DDS S.BERNARDINO STD W/HI DDS 10/10 FLAT GR-RX06 RIVERSIDE STD W/HI OP DDS S.D. VALUE STD W/HI OP DDS LOS ANGLES II STD W/HI DDS SAN DIEGO I STD W/HI DDS 5/25 HI GR-RX07 5/25 LO GR-RX07 SAN MATEO STD W/HI OP DDS VENTURA STANDARD W/HI DDS SV 30-40/350A+70% 06 7/7 GR-RX06 5/65 HI GR-RX07 SV 30-40/350A+70% 06 AB 5/65 LO GR-RX07 SV 30-40/350A+70% 06 CB 10/20/30 GR-RX06 ORANGE I STD W/ HI OP DDS ORANGE SECURE GOLD LOS ANGELES I STD W/HI DDS SAN DIEGO I STD W/HI DDS 8.50/26.45/50% SH6 10/20/35 GR-RX06 5/10 HI GR-RX07 10/20 I GR-RX06 5/10 LO GR-RX07 8.50/26.45/50% SH6 10/20 GR-RX06 5/10/20 HI GR-RX07 5/10/20 LO GR-RX07 5/10 GR-RX06 8.50/26.70/50% SH6 10/10 GR-RX06 KERN STANDARD W/HI OPT DDS KERN STANDARD W/HI DDS 51 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 6KH 6KK 6KL 6KM 6KN 6KP 6KR 6L2 6LA 6LE 6LG 6LH 6LL 6LM 6LN 6LO 6LP 6LS 6LV 6MA 6ME 6MH 6ML 6MM 6MO 6MP 6N2 6N3 6ND 6NH 6NL 6NP 6NR 6OE 6OG 6OR 6PH 6PL 6PP 6QH 6QL 6QM 6R2 6RG 6RH 6RI 6RL 6RM 6RN 6RR Plan / Benefit Description 7/14 HI GR-RX07 KERN STANDARD W/HI OPT DDS 7/14 LO GR-RX07 5/10/20 GR-RX06 SH KERN STD - ENDORSED GRP 8.50/26.70/50% SH6 10/20/35 GR-RX06 LOS ANGLES II STD W/HI DDS LOS ANGELES SECURE GOLD LOS ANGELES I STD W/HI DDS LOS ANGELES I STD W/HI DDS 7/20/50% HI GR-RX7 7/20/50% LO GR-RX7 5/15 GR-RX06 LOS ANGELES I STD W/HI DDS RESERVED 8.50/26.70/50% SH6 SH LOS ANGELES PLUS PLAN L.A. VALUE STD W/HI OP DDS 10/25%/40% RX-GR06 ALAMEDA I STD W/HI OPT DDS 10/20 HI GR-RX07 10/20 LO GR-RX07 SAN MATEO STD. W/HI DDS SAN MATEO STD W/HI OP DDS 8.50/26.75/50% SH6 ORANGE II STD W/HI OP DDS SAN DIEGO III STD W/HI DDS S.BERNARDINO STD W/HI DDS 10/20/40 HI GR-RX7 10/20/40 LO GR-RX7 8.50/26.75/50% SH6 S.BERNARDINO STD W/HI DDS ORANGE I STD W/ HI OP DDS ORANGE STANDARD W/HI DDS SH ORANGE PLUS PLAN 10/20 HI GR-RX07 10/20 LO GR-RX07 8.50/26.85/50% SH6 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 5/15/30 GR-RX06 CNTRA CSTA II STD W/HI DDS ORANGE STD W/HI OP DDS 10/20/35 HI GR-RX7 RIVERSIDE STD W/HI OP DDS 10/20/35 LO GR-RX7 5/15/30 GR-RX06 KERN STANDARD W/HI OPT DDS SH RIVERSIDE PLUS PLAN 52 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 6RS 6RV 6SB 6SG 6SH 6SI 6SJ 6SK 6SL 6SM 6SN 6SO 6SP 6SR 6SX 6T2 6TA 6TH 6TL 6TM 6TP 6TU 6UC 6UH 6UL 6UP 6V3 6VE 6VM 6VP 6VR 6WH 6WI 6WM 6WP 6WR 710 711 712 713 714 715 716 717 718 719 71A 71B 71C 71D Plan / Benefit Description RIVERSIDE SECURE GOLD RIVERSIDE STD. W/HI DDS SH SAN BERNARDINO PLUS PLN SH SAN DIEGO PLUS PLAN 10/25/55 HI GR-RX7 10/20/40 I GR-RX06 S. BERNARDINO STD W/HI DDS SANTA CLARA STD. W/HI DDS 10/25/55 LO GR-RX7 SH SACRAMENTO PLUS PLAN SH SAN FRANCISCO PLUS PLAN RESERVED SAN DIEGO I STD. W/HI DDS 10/20/40 GR-RX06 SH SANTA CLARA PLUS PLAN CNTRA CSTA II STD W/HI DDS SANTA CLARA STD W/HI DDS 10/40/75 HI GR-RX7 10/40/75 LO GR-RX7 5/5 GR-RX06 4.50/14.50/50% SH6 VENTURA STANDARD W/HI DDS 10/20/35 GR-RX06 15/25/40 HI GR-RX7 15/25/40 LO GR-RX7 25%/25%/25% SH6 L.A. VALUE STD W/HI OP DDS VENTURA STANDARD W/HI DDS 5/5 GR-RX06 25%/25%/25% SH6 VENTURA STANDARD W/HI DDS 10/25/50 HI GR-RX7 15/25/40 I GR-RX06 5/7.50 GR-RX06 8.50/26.45/50% SH6 15/25/40 GR-RX06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 53 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 71E 71F 71G 71H 71I 71J 71K 71L 71M 71N 71O 71P 71Q 71R 71S 71T 71U 71V 71W 71X 71Y 71Z 720 721 722 723 724 725 726 727 728 729 72A 72B 72C 72D 72E 72F 72G 72H 72I 72J 72K 72L 72M 72N 72O 72P 72Q 72R Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 54 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 72S 72T 72U 72V 72W 72X 730 731 732 733 734 735 736 737 738 739 73A 73B 73C 73D 73E 73F 73G 73H 73I 73J 73K 73L 73M 73N 73O 73P 73Q 73R 73S 73T 73U 73V 73W 73X 73Y 73Z 740 741 742 743 744 745 746 747 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 55 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 748 749 74A 74B 74C 74D 74E 74F 74G 74H 74I 74J 74K 74L 74M 74N 74O 74P 74Q 74R 74S 74T 74U 74V 74W 74X 74Y 74Z 750 751 752 753 754 755 756 757 758 759 75A 75B 75C 75D 75E 75F 75G 75H 75I 75J 75K 75L Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 56 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 75M 75N 75O 75P 75Q 75R 75S 75T 75U 75V 75W 75X 75Y 75Z 760 761 762 763 764 765 766 767 768 769 76A 76B 76C 76D 76E 76F 76G 76H 76I 76J 76K 76L 76M 76N 76O 76P 76Q 76R 76S 76T 76U 76V 7A2 7A3 7AD 7AE Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPOO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO ALAMDA II PLS PLN W/OP DDS L.A. VALUE PLS PLN W/DDS ALAMEDA I PLS PLN W/OP DDS ALAMEDA I PLS PLN W/OP DDS 57 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 7AL 7AQ 7AR 7B1 7B2 7BB 7BD 7BH 7BI 7BL 7BR 7CC 7CD 7CI 7CL 7CM 7CQ 7D2 7D3 7DD 7DE 7DG 7DH 7DI 7DL 7DM 7DN 7DO 7DR 7DS 7DV 7E2 7ED 7EG 7EH 7EL 7EM 7ER 7FA 7FD 7FH 7FL 7FM 7FR 7GD 7GE 7GL 7GM 7GO 7GR Plan / Benefit Description ALMAMEDA PT B PL W/ NO DEN 7/20 GR-RX07 0/0 GR-RX07 SH PART B PLUS MED W/$12 SH PART B PLUS W/$62 PREM. SH PART B PLS: SD, IM & VT 7/14 GR-RX07 4/10/20 T1A H GRX7 7/14 I GR-RX07 4/10/20 T1A L GRX7 0/0 FLAT GR-RX07 CONTRA COSTA B PL W/ NO DE 7/14 GR-RX07 7/14 I GR-RX07 S.CLARA PLS PLN W/OPT DDS 15/25/40 GR-RX07 5/29/60 W/G SH-RX7 ALAMDA II PLS PLN W/OP DDS S.DIEGO III PLUS W/OP DDS 7/20/30 GR-RX07 RIVERSIDE PLS PLN W/OP DDS S.DIEGO I PLS PLN W/OP DDS 4/15/30 T1B H GRX7 S.DIEGO III PLUS W/OP DDS 4/15/30 T1B L GRX7 15/25/40 GR-RX07 S. BERDO PLS PLN W/OP DDS S. BERDO PLS PLN W/OP DDS 10/10 FLAT GR-RX07 RIVERSIDE PLS PLN W/OP DDS S.D. VALU PLS PLN W/OP DDS L.A. II PLUS PLAN W/OP DDS 7/7 GR-RX07 S.DIEGO I PLS PLN W/OP DDS 4/20/40 T1C H GRX7 4/20/40 T1C L GRX7 3/3 FLAT GR-RX07 10/20 GR-RX07 25% PART D GR-RX07 7/7 C GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 3/3/3 GR-RX07 10/20 GR-RX07 10/20/30 GR-RX07 ORANGE I PLS PLN W/OP DDS L.A. I PLUS PLAN W/OPT DDS 5/10 GR-RX07 S.DIEGO I PLS PLN W/OP DDS 10/20 GR-RX07 58 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 7HH 7HI 7HL 7HR 7JH 7JL 7JM 7JR 7KH 7KI 7KL 7KM 7KR 7L2 7LA 7LE 7LG 7LH 7LL 7LM 7LN 7LR 7LV 7M2 7MA 7ME 7MH 7MI 7ML 7MR 7MT 7N2 7N3 7ND 7NH 7NL 7NM 7NR 7OC 7OE 7OG 7PH 7PI 7PL 7PM 7PR 7Q5 7Q6 7Q7 7QH Plan / Benefit Description 4/15/30 T2A H GRX7 10/20 I GR-RX07 4/15/30 T2A L GRX7 10/20 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/10 GR-RX07 10/10 GR-RX07 4/28/55 T3B H GRX7 10/20/35 I GR-RX07 4/28/55 T3B L GRX7 5/10/20 GR-RX07 10/20/35 GR-RX07 L.A. II PLUS PLAN W/OP.DDS SH LA PT B PL W/ NO DENTAL L.A. I PLUS PLAN W/OPT DDS L.A. I PLUS PLAN W/OPT DDS 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 5/15 GR-RX07 L.A. I PLUS PLAN W/OPT DDS 15/25/40 GR-RX07 L.A. VALUE PLS PLN W/DDS SACTO II PLS PLN W/OP DDS 10/25%/40% GR-RX07 ALAMEDA I PLS PLN W/OP DDS 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 10/20/40 GR-RX07 SACTO I PLS PLN W/OP DDS ORANGE II PLS PLN W/OP DDS S.DIEGO III PLUS W/OPT DDS S. BERDO PLS PLN W/OP DDS 4/25/50 T2C H GRX7 4/25/50 T2C L GRX7 5/15/30 GR-RX07 S. BERDO PLS PLN W/OP DDS SH ORANGE PT B PL W/ NO DE ORANGE I PLS PLN W/OP DDS ORANGE PLUS PLAN W/ OP.DDS 4/25/50 T2C H GRX7 10/20/40 I GR-RX07 4/25/50 T2C L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 5/29/57.20W/G SHX7 5/29/57.95W/G SHX7 5/29/58 W/G SH-RX7 4/20/40 T2B H GRX7 59 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 7QI 7QL 7QM 7QR 7RA 7RB 7RC 7RD 7RG 7RH 7RI 7RL 7RM 7RS 7RV 7SA 7SB 7SC 7SD 7SE 7SF 7SH 7SI 7SJ 7SK 7SM 7SP 7SR 7TA 7TH 7TL 7TM 7TO 7TR 7UC 7UH 7UL 7UM 7UR 7V3 7VH 7VL 7VM 7WE 7WH 7WI 7WL 7WM 7WP 7WR Plan / Benefit Description 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 ORANGE PLUS PLN W/OP DDS 4/15/30 T2A H GRX7 RIVERSIDE PLS PLN W/OP DDS 4/15/30 T2A L GRX7 5/15/30 GR-RX07 RIVERSIDE PT B PL W/ NO DE RIVERSIDE PLS PLN W/OP.DDS SH SACRAM PT B PL W/ NO DE 10/25%/40% GR-RX07 S CLARA PT B PL W/ NO DENT S DIEGO PT B PL W/ NO DENT S BERNARD PT B PL W/ NO DE SH S FRAN PT B PL W/ NO DE SACRMNTO PLS PLN W/OPT.DDS 10/20/40 I GR-RX07 SAN BERDO PLS PLN W/OP.DDS S.CLARA PLS PLN W/OPT. DDS S0NOMA CLASSIC I S.DIEGO I PLS PLN W/OP.DDS 10/20/40 GR-RX07 S.CLARA PLS PLN W/OPT DDS 4/28/55 T3B H GRX7 4/28/55 T3B L GRX7 5/5 GR-RX07 SACTO I PLS PLN W/OP DDS 10/25/40 GR-RX07 10/20/35 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/5 GR-RX07 15/25/40 GR-RX07 L.A. VALUE PLS PLN W/DDS 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 5/5 GR-RX07 SONOMA CLASSIC I W/EPO DDS 4/20/40 T1C H GRX7 15/25/40 I GR-RX07 4/20/40 T1C L GRX7 5/7.50 GR-RX07 SONOMA CLASSIC I W/ODP DDS 15/25/40 GR-RX07 60 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 7XA 7XB 7XC 7XD 7XE 7XF 7XG 7XH 7XJ 7XL 7XM 7XP 7XQ 7XR 7XS 7XT 7XU 7XY 7XZ 7YH 7YI 7YL 7YM 7YR 7ZH 7ZL 7ZM 7ZR 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 82A 82B Plan / Benefit Description 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/25/50 RDS GR-RX7 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/15/30 T1B H GRX7 4/25/50 RDS GR-RX7 4/15/30 T1B L GRX7 7/14 GR-RX07 5/29/60 N/G SH-RX7 5/29/60 W/G SH-RX7 5/29/60 N/G 3 SHX7 5/29/60 5G SH-RX7 5/29/60 10G SH-RX7 5/28/64 N/G SH-RX7 25% N/G SH-RX7 5/35/65 NGE SH-RX7 4/10/20 T1A H GRX7 15/25/40 I GR-RX07 4/10/20 T1A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED OOI RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 61 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 82C 82D 82E 82F 82G 82H 82J 82K 82L 82M 82N 82P 82Q 82R 82S 82T 82U 82V 82W 82X 82Y 82Z 830 831 832 833 834 835 836 837 838 839 83A 83B 83C 83D 83E 83F 83G 83H 83J 83K 83L 83M 840 841 842 843 844 845 Plan / Benefit Description 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 62 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 880 881 8A2 8A3 8AD 8AE 8AH 8AM 8AR 8B3 8B5 8B8 8B9 8BH 8BL 8BN 8BW 8C8 8CH 8CL 8CT 8D2 8D3 8DD 8DE 8DG Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX OOI RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 880 PLAN INACTIVE 880 PLAN ALAMDA II PLS PLN W/HI DDS L.A.VALUE PLS PLN W/HI DDS ALAMEDA I PLS PLN W/HI DDS ALAMEDA I PLS PLN W/HI DDS 0/0 HI C GR-RX07 SH ALAMEDA STD W/OPT DNTL 0/0 C GR-RX07 MCC VENTURA LO-PL SH07 MCC VENTURA HI-PL SH07 5/29/60NG RX-SH08 MCC VENTURA PLUS SH07 MCC VENTURA HIGH SH07 MCC VENTURA LOW SH07 MC COMP VENTURA SH07 OK TO USE 5/29/60NG RX-SH08 2/30/60 HI C GRX07 S.CLARA PLS PLN W/HI DDS SH CONTRA COSTA STD-LO DNT ALAMDA II PLS PLN W/HI DDS S.DIEGO III PLUS W/HI DDS 7/20/30 C GR-RX07 RIVERSIDE PLS PLN W/HI DDS S.DIEGO I PLS PLN W/HI DDS 63 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 8DH 8DI 8DN 8DO 8DR 8DS 8DV 8E2 8E8 8ED 8EG 8EH 8EM 8ER 8F8 8FD 8FH 8G8 8GE 8GH 8GL 8GM 8GO 8H3 8H5 8H9 8HD 8HH 8HL 8HN 8J8 8JH 8JL 8JW 8JX 8K3 8K5 8KH 8KL 8KM 8KN 8KO 8KR 8KV 8KW 8KX 8L2 8LE 8LG 8LH Plan / Benefit Description 2/40 HI C GR-RX07 S.DIEGO III PLUS W/HI DDS S. BERDO PLS PLN W/HI DDS S. BERDO PLS PLN W/HI DDS 10/10 FLAT C GRX07 RIVERSIDE PLS PLN W/HI DDS S.D. VALU PLS PLN W/HI DDS L.A. II PLUS PLAN W/HI DDS 6/40/80NG RX-SH08 7/7 C GR-RX07 S.DIEGO I PLS PLN W/HI DDS 5/25 HI C GR-RX07 3/3 FLAT C GR-RX07 10/20 C GR-RX07 6/41/80NG RX-SH08 7/7 C GR-RX07 5/65 HI C GR-RX07 6/42/85NG RX-SH08 ORANGE I PLS PLN W/HI DDS 5/10 HI C GR-RX07 L.A. I PLUS PLAN W/HI DDS 5/10 C GR-RX07 S.DIEGO I PLS PLN W/HI DDS MCC ESS VENTURA LO-PL SH07 MCC ESS VENTURA HI-PL SH07 MCC ESS VENTURA PLUS SH07 10/20/30 C GR-RX07 MCC ESS VENTURA HIGH SH07 MCC ESS VENTURA LOW SH07 MC COMP ESS VENTURA SH07 5/34/79NG RX-SH08 ARP MCC 1 S BERDO HI SH08 ARP MCC 1 S BERDO LO SH08 ARP MCC 1 S BERDO SH08 ARP MCC 1 S BERDO DLX SH08 ARP MCC 1 LA LO-PL SH08 ARP MCC 1 LA HI-PL SH08 ARP MCC 1 LA HI SH08 ARP MCC 1 LA LO SH08 5/10/20 C GR-RX07 RESERVED ARP MCC 1 LA PL-DLX SH08 SH KERN STANDARD W/LO DNTL ARP MCC 1 LA PLUS SH08 ARP MCC 1 LA SH08 ARP MCC 1 LA DLX SH08 L.A. II PLUS PLAN W/HI DDS L.A. I PLUS PLAN W/HI DDS L.A. I PLUS PLAN W/HI DDS 7/20/50% HI C GRX7 64 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 8LM 8LN 8LV 8M3 8M5 8M8 8MA 8ME 8MH 8ML 8MO 8MV 8MW 8MX 8N2 8N3 8N8 8ND 8NH 8NL 8NM 8NR 8NW 8NX 8OE 8OG 8P8 8PH 8PM 8Q8 8R8 8RG 8RH 8RI 8RM 8RR 8RU 8RV 8S8 8SB 8SC 8SE 8SG 8SH 8SI 8SJ 8SK 8SM 8SN 8SO Plan / Benefit Description 5/15 C GR-RX07 L.A. I PLUS PLAN W/HI DDS L.A.VALUE PLS PLN W/HI DDS ARP MCC 2 LA LO-PL SH08 ARP MCC 2 LA HI-PL SH08 5/36/82NG RX-SH08 10/25%/40% C GRX07 ALAMEDA I PLS PLN W/HI DDS ARP MCC 2 LA HI SH08 ARP MCC 2 LA LO SH08 ARP MCC 2 LA PL-DLX SH08 ARP MCC 2 LA PLUS SH08 ARP MCC 2 LA SH08 ARP MCC 2 LA DLX SH08 ORANGE II PLS PLN W/HI DDS S.DIEGO III PLUS W/HI DDS 5/29/60G RX-SH08 S. BERDO PLS PLN W/HI DDS ARP MCC 3 S BERDO HI SH08 ARP MCC 3 S BERDO LO SH08 5/15/30 C GR-RX07 S. BERDO PLS PLN W/HI DDS ARP MCC 3 S BERDO SH08 ARP MCC 3 S BERDO DLX SH08 ORANGE I PLS PLN W/HI DDS ORANGE PLUS PLAN W/HI DDS 5/29/60G RX-SH08 10/20 HI C GR-RX07 5/15/30 C GR-RX07 5/37/71G RX-SH08 5/37/71G RX-SH08 ORANGE PLS PLN W/HI OP DDS 10/20/35 HI C GRX7 RIVERSIDE PLS PLN W/HI DDS 5/15/30 C GR-RX07 SH RIVERSIDE STD W/OPT DNT 15/25/40 C GR-RX07 RIVERSIDE PLS PLN W/HI DDS 5/29/60G RX-SH08 SH SAN BERN STD W/OPT DNTL STANISLAUS CLASSIC I STANISLAUS CLSC I W/EPODDS SH SAN DIEGO STD W/OP DNTL 10/25/55 HI C GRX7 RESERVED SAN BERDO PLS PLN W/HI DDS S.CLARA PLS PLN W/HI DDS SH SACRAMENTO STD W/OP DNT SH SAN FRAN STD W/OPT DNTL RESERVED 65 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 8SP 8SU 8SW 8SX 8SY 8T8 8TA 8TH 8TM 8TR 8TU 8TW 8TY 8U3 8U5 8UH 8UL 8UM 8UO 8UR 8UV 8UW 8UX 8V3 8VJ 8VM 8VN 8WH 8WP 8Y3 8Y5 8YH 8YL 8YO 8YV 8YW 8YX 8Z1 8ZU 8ZW 8ZY 910 911 912 913 914 915 916 917 918 Plan / Benefit Description S.DIEGO I PLS PLN W/HI DDS ARP MCC SONOMA PP SH08 ARP MCC SONOMA SH08 SH SANTA CLARA STD-OP DNTL ARP MCC SONOMA EP SH08 5/29/60G RX-SH08 S.CLARA PLS PLN W/HI DDS 10/40/75 HI C GRX7 5/5 C GR-RX07 10/25/40 C GR-RX07 NOT USED ARP MCC ES NO SH08 NOT USED ARP MCC 3 LA LO-PL SH08 ARP MCC 3 LA HI-PL SH08 ARP MCC 3 LA HI SH08 ARP MCC 3 LA LO SH08 5/5 C GR-RX07 ARP MCC 3 LA PL-DLX SH08 15/25/40 C GR-RX07 ARP MCC 3 LA PLUS SH08 ARP MCC 3 LA SH08 ARP MCC 3 LA DLX SH08 L.A.VALUE PLS PLN W/HI DDS VEBA B15 $15/$100/$500 AB 5/7.50 C GR-RX07 SH VENTURA STD-I W/OP DNTL 10/25/50 HI C GRX7 STANISLAUS CLSC I W/ODPDDS ARP MCC VA LA LO-PL SH08 ARP MCC VA LA HI-PL SH08 ARP MCC VA LA HI SH08 ARP MCC VA LA LO SH08 ARP MCC VA LA PL-DLX SH08 ARP MCC VA LA PLUS SH08 ARP MCC VA LA SH08 ARP MCC VA LA DLX SH08 880 PLAN (COBRA) ARP MCC STANLUS PP SH08 ARP MCC STANLUS SH08 ARP MCC STANLUS EP SH08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 66 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 919 91H 920 921 922 923 924 925 926 927 928 929 92H 930 931 932 933 934 935 936 937 938 939 93H 940 941 942 943 944 945 946 947 948 949 94H 950 951 952 953 954 955 956 957 958 959 95E 95H 95N 95P 960 Plan / Benefit Description RESERVED PPO 15/25/40 HI GR-RX8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/25/50 HI GR-RX8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20/40 HI GR-RX8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20 HI GR-RX08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO MCC SAN FRAN EP SH07 10/40/75 HI C GRX8 MC COMP SAN FRAN SH07 MCC SAN FRAN PP SH07 RESERVED RX PPO 67 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 961 962 963 964 965 966 967 968 969 96D 96E 96N 96P 970 971 972 973 974 975 976 977 978 979 97E 97M 97N 97P 980 981 982 983 984 985 986 987 988 989 98E 98N 98P 990 991 992 993 994 99E 99N 99P 9AM 9AN Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO MCC SAN JOAQUN DELUXE SH07 MCC SAN JOAQUN EP SH07 MC COMP SAN JOAQUN SH07 MCC SAN JOAQUN PP SH07 BENEFIT RESERVED PPO BENEFIT RESERVED PPO BENEFIT RESERVED PPO BENEFIT RESERVED PPO BENEFIT RESERVED PPO BENEFIT RESERVED PPO BENEFIT RESERVED PPO BENEFIT RESERVED PPO BENEFIT RESERVED PPO BENEFIT RESERVED PPO MCC SON0MA EP SH07 DO NOT USE MC COMP S0NOMA SH07 MCC SON0MA PP SH07 BENEFIT RESERVED PPO BENEFIT RESERVED PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO MCC STANISLAUS EP SH07 MC COMP STANISLAUS SH07 MCC STANISLAUS PP SH07 RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO MCC ESS STANLAUS EP SH07 MC COMP ESS STANLAUS SH07 MCC ESS STANLAUS PP SH07 SH ALAMEDA STD W/ HI DNTL 4/20/40 LO GR-RX08 68 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 9AQ 9AR 9AY 9BE 9BH 9BL 9BR 9CM 9CT 9DF 9DH 9DL 9DR 9EH 9EL 9ER 9FD 9FH 9FL 9GE 9GM 9HD 9HH 9HK 9HL 9HN 9HP 9HQ 9HR 9HS 9HT 9HU 9HV 9HW 9HX 9HY 9HZ 9JH 9JL 9KH 9KL 9KN 9KR 9KS 9KU 9LA 9LG 9LH 9LL 9LM Plan / Benefit Description 7/20 GR-RX08 0/0 GR-RX08 4/25/50 HI GR-RX08 7/14 GR-RX08 4/10/20 T1A H GRX8 4/10/20 T1A L GRX8 S. BERDO CNTY SECURE GOLD 15/25/40 GR-RX08 SH CONTRA COSTA STD-HI DNT 10/10 FLAT GR-RX08 4/15/30 T1B H GRX8 4/15/30 T1B L GRX8 10/10 FLAT C GRX08 4/20/40 T1C H GRX8 4/20/40 T1C L GRX8 10/20 GR-RX08 7/7 C GR-RX08 4/25/50 T1D H GRX8 4/25/50 T1D L GRX8 10/20/30 GR-RX08 5/10 GR-RX08 10/20/30 C GR-RX08 4/15/30 T2A H GRX8 4/10/20 RX-GR08 4/15/30 T2A L GRX8 4/15/30 RX-GR08 5/30/45 GRRX08 4/20/40 RX-GR08 4/25/50 RX-GR08 10/25/50 RX-GR08 4/15/30 RX-GR08 4/20/40 RX-GR08 4/25/50 RX-GR08 5/20/45 RX-GR08 4/25/45 RX-GR08 4/28/55 RX-GR08 4/28/58 RX-GR08 4/28/58 T3C H GRX8 4/28/58 T3C L GRX8 4/28/55 T3B H GRX8 4/28/55 T3B L GRX8 RESERVED SH KERN STD W/HI OPT DENTL 10/20/35 GR-RX08 10/20/40 RX-GR08 L.A. COUNTY SECURE GOLD L.A. COUNTY SECURE GOLD 4/25/45 T3A H GRX8 4/25/45 T3A L GRX8 5/15 C GR-RX08 69 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 9LO 9LP 9LR 9LS 9LV 9LX 9MA 9MH 9MI 9ML 9MR 9NH 9NL 9NM 9OC 9OG 9OK 9OR 9PH 9PI 9PL 9PW 9PX 9PY 9QH 9QL 9RD 9RH 9RI 9RL 9RP 9RR 9RX 9SA 9SB 9SD 9SG 9SI 9SL 9SN 9SO 9SX 9TE 9TH 9TL 9TN 9TP 9UC 9UH 9UL Plan / Benefit Description RESERVED 5/15 GR-RX08 10/20/50 GR-RX08 SH LA STD W/HI OPT DENTAL 10/20/35 RX-GR08 10/20/35 RX-GR08 10/25%/40% GR-RX08 4/20/40 T2B H GRX8 10/20/40 I GR-RX08 4/20/40 T2B L GRX8 10/20/40 GR-RX08 4/25/50 T2C H GRX8 4/25/50 T2C L GRX8 5/15/30 GR-RX08 ORANGE COUNTY SECURE GOLD ORANGE COUNTY SECURE GOLD 5/15/25/25 GR-RX08 SH ORANGE STD W/HI OP DNTL 4/25/50 T2C H GRX8 RX RETIREE TPIG $5G/10B UN 4/25/50 T2C L GRX8 5/29/60 P RX-GR08 5/29/60 P RX-GR08 5/29/60 P RX-GR08 4/20/40 T2B H GRX8 4/20/40 T2B L GRX8 RIVERSIDE CNTY SECURE GOLD 4/15/30 T2A H GRX8 RIVERSIDE CNTY SECURE GOLD 4/15/30 T2A L GRX8 5/15/30 GR-RX08 SH RIVERSIDE STD W/HI DNTL NO RX S. BERDO CNTY SECURE GOLD SH SAN BERN STD W/HI DENTL S. DIEGO CNTY SECURE GOLD SH SAN DIEGO STD W/HI DNTL RESERVED SH LOS ANGELES STD -HI DNT SH SAN FRAN STD W/HI DENTL RESERVED SH SANTA CLARA STD-HI DNTL STANISLAUS MEDCL W/EPO DDS 4/28/55 T3B H GRX8 4/28/55 T3B L GRX8 STANISLAUS MEDICAL STANISLAUS MEDCL W/ODP 10/20/35 GR-RX08 4/28/58 T3C H GRX8 4/28/58 T3C L GRX8 70 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit 9VH 9VJ 9VL 9VM 9VN 9WH 9WI 9WL 9WM 9XH 9XL 9YH 9YL 9ZH 9ZL A A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14 A15 A16 A17 A18 A19 A1C A1G A1I A1J A1L A1Y A1Z A20 A21 A22 A23 A24 A25 A26 A27 Plan / Benefit Description 4/25/50 T1D H GRX8 SV 10/80% PVH 05 AB 4/25/50 T1D L GRX8 5/5 GR-RX08 SH VENTURA STD-I W/HI DNTL 4/20/40 T1C H GRX8 15/25/40 I GR-RX08 4/20/40 T1C L GRX8 5/7.50 GR-RX08 4/15/30 T1B H GRX8 4/15/30 T1B L GRX8 4/10/20 T1A H GRX8 4/10/20 T1A L GRX8 4/25/45 T3A H GRX8 4/25/45 T3A L GRX8 THIS IS A TEST PPO SERIES A PLAN 1 PPO SERIES A PLAN 2 PPO SERIES A PLAN 3 PPO SERIES A PLAN 4 PPO SERIES A PLAN 5 PPO SERIES A PLAN 6 PPO SERIES A PLAN 7 PPO SERIES A PLAN 8 PPO SERIES A PLAN 9 PPO SERIES A PLAN 10 SERIES A NATL PLAN 1 SERIES A NATL PLAN 2 SERIES A NATL PLAN 3 SERIES A NATL PLAN 4 SERIES A NATL PLAN 5 SERIES A NATL PLAN 6 SERIES A NATL PLAN 7 SERIES A NATL PLAN 8 SERIES A NATL PLAN 9 PREFERRED PLAN II GM HRLY HMO 2001 PASTEUR INDIVIDUAL CONV PL SV ABC APPRN TRST-HIGH AB ALAMEDA STANDARD PLAN GM HRLY HMO 2001 COBRA PREFERRED PLAN COBRA II SERIES A NATL PLAN 10 PPO SERIES A PLAN 1-COBRA PPO SERIES A PLAN 2-COBRA PPO SERIES A PLAN 3-COBRA PPO SERIES A PLAN 4-COBRA PPO SERIES A PLAN 5-COBRA PPO SERIES A PLAN 6-COBRA PPO SERIES A PLAN 7-COBRA 71 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit A28 A29 A2A A2D A2E A2H A2J A2P A2S A30 A31 A32 A33 A34 A35 A36 A37 A38 A39 A3C A3D A3E A3J A3L A3M A3S A3Z A40 A42 A4A A4J A4L A4T A4W A5J A5L A63 A64 A65 A6C A6D A6J A6L A73 A74 A75 A7F A7J A7L A7Z Plan / Benefit Description 23O SERIES A PLAN 8-COBRA PPO SERIES A PLAN 9-COBRA NON STANDARD $10/$250 ALAMEDA CLSC II W/OPT DDS ALAMEDA CLSC II W/EPO DDS ALAMEDA CLSC II W/HI DDS SV 10/100% CTYANHM 06 AB SV 10/100% CTYANHM 06 CB ALAMEDA CLASSIC II PPO SERIES A PLAN 10-COBRA SERIES A NATL PLAN 1-COBRA SERIES A NATL PLAN 2-COBRA SERIES A NATL PLAN 3-COBRA SERIES A NATL PLAN 4-COBRA SERIES A NATL PLAN 5-COBRA SERIES A NATL PLAN 6-COBRA SERIES A NATL PLAN 7-COBRA SERIES A NATL PLAN 8-COBRA SERIES A NATL PLAN 9-COBRA PRFD PLAN FHP FAMILY SEC ALAMEDA MEDICAL W/OPT DDS ALAMEDA MEDICAL W/EPO DDS SV ABC APPRN TRST-APPRN AB ALAMEDA PLUS PLAN ALAMEDA MEDICAL ALAMEDA MEDICAL W/HIOP DDS PRFD PLAN FHP FAM SEC COBR SERIES A NATL PLAN 10-COBR 10/12V 1YR ACU GR07 FOOTWARE FOR DISFIGUREMENT AMR UNION $5/$350A AB ALAMEDA STAND. W/OPT. DDS ATW-STD GR-WL07 ATW-PLUS GR-WL07 SV ABC APPRN TRST-LOW AB ALAMEDA STANDARD W/HI DENT KEC 1 AMEDA CG GR07 KEC 1 AMEDA LO CG GR07 KEC 1 AMEDA HI CG GR07 $5/6VSTS/YR ACUPUNCTURE 06 SV 15-25/200A ADP 06 AMR UNION $10/350A AB ALAMEDA PLUS PLN W/OPT DDS KEC 1 AMEDA CGII GR07 KEC 1 AMEDA LO CGII GR07 KEC 1 AMEDA HI CGII GR07 SV 5/100% AFSCME 05 SV 5/100% AFSCME 05 AB ALAMEDA PLUS PLAN W/HI DNT SV 5/100% AFSCME 05 CB 72 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit A83 A84 A85 A8J A9J AAA AAB AAC AAF AAG AAH AAJ AAM AAN AAR AAT AAV AAX AAY AAZ AB2 ABA ABC ABH ABJ ABP ABT ABZ AC1 AC2 AC3 AC4 AC5 AC6 AC7 AC8 AC9 ACA ACB ACC ACD ACE ACF ACH ACI ACJ ACK ACL ACP ACQ Plan / Benefit Description KEC 1 AMEDA CGEH GR07 KEC 1 AMEDA LO CGEH GR07 KEC 1 AMEDA HI CGEH GR07 AMR UNION $20/$350A AB SP $10/100 AZUSA PU AB SV 15/250A SNTAROSA 05 SV 10-20/100D AIW SEL05 SV 15/250A ABC APRNT 05 CB SV 15/250A ADMSTFF 06 SV 20/250A ASCENT 07 SV 10/100% ABC APPREN 05CB SP 15/100% ALDILA AB 15/20V ACU/CHIRO 07 SV 10/100% ABC 06 SV 20/100% AIR-C&R 06 SV 15/250A ABC APRNTC 05 SV 20-40/80% AI 07 SV 15/250A ADMSTFF 06 AB SV 10-20/100D AIW SEL05 CB SV 15/250A ADMSTFF 06 CB SP 20/100A AGC 05 CB SV 15/250A SNTAROSA 05 CB US BORAX-PC US BEHAVIORAL HEALTH CARE SP 20/100A AGC 05 AB SV 15/250A ABC 06 SP 20/100A AGC 05 US BORAX-PC $5/$5/40V ACU/CHIRO/HERBAL $5/$5/20V ACU/CHIRO/HERBAL $10/$5/30V ACU/CHIRO/HERBA $10/$5/40V ACU/CHIRO/HERBA $15/$5/20V ACU/CHIRO/HERBA $5/$5/40V ACU/CHIRO/HERBAL $10/$5/30V ACU/CHIRO/HERBA $10/30V ACU/CHIRO $5/$5/40V ACU/CHIRO $5/$5/20V ACU/CHIRO $10/$10/30V ACU/CHIRO SCRIPPS CUSTOM HMO $10/$10 40V ACU/CHIRO $15/$15/20V ACU/CHIRO ADMINS/CONSULTANTS FEE $10/$10/40V ACU/CHIRO ACCUPUNCTURE - PLHIC SV 15/250A ABC APRNT 05 AB 15/20V ACU/CH06 10/30V ACU/CHIRO 07 SCRIPPS CUSTOM POS 5/40V ACU/CHIRO 07 73 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ACR ACS ACT ACW ACY ACZ AD3 AD6 ADA ADC ADE ADG ADH ADJ ADL ADM ADP ADR ADS ADU ADV ADX ADY ADZ AEC AED AEF AEJ AEP AET AEU AEX AEZ AF2 AF3 AFA AFC AFH AFJ AFK AFM AFN AFS AFX AFZ AG2 AG3 AGA AGB AGC Plan / Benefit Description PPO ACCUPUNTURE RIDER HOSPITAL CAP SUPPRESSION SV 20/250A + 20% ABC 06 5/20V ACU/CHIRO 07 SCRIPPS CUSTOM POS COBRA SCRIPPS CUSTOM HMO COBRA ADMINISTAFF $15/$250A SV 15/250A ADMIN ADMINISTAFF HMO $10/$250 SV 20/350A HTAU 06 ENDORS ALAM BASIC W/ NO DE SV 20/250A ASCENT 07 CB ALCOHOL/DRUG REHAB-HIGH ADMINISTAFF $15/$250A AB ALCOHOL/DRUG REHAB-LOW SV 15/100% AGCHWT 06 SV 15-25/200A ADP SV 20/100% AIR-C&R 06 CB SV 15-25/200A ADP 06 SV 15-25/200A ADP 06 CB SV 15-25/200A ADP 06 AB SV 15-25/200A ADP 06 AB SV 15-25/200A ADP 06 CB ADMINISTAFF COBRA $10/$250 SV 15-30/250A ADP 05 SV 15-25/200A ADP 07 EXECUFIT WELLNESS PROGRAM SV 10-20/100D AIW SEL05 AB ALAMEDA CLSC I W/EPO DDS 10/30V ACU/CHIRO 07 15/20V ACU/CHIRO 07 SV 15-30/250A ADP 05 AB SV 15-30/250A ADP 05 CB ST. ANTHONY $10/100 MFP ST. ANTHONY $10/100 MFP CB SV 15/100% AME HONDA 06 CTY FRESNO DRCT PAY ADM RETENTION FEE SV 15/250A SNTAROSA 05 AB 15/20V ACU/CHIRO 07 SV 15/100% AGCHWT 06 CB SV 10/100% ABC 06 CB ADMINISTRATIVE SERVICE FEE SV 15/100% AME HONDA 06 AB SV 15/100% AME HONDA 06 CB AGILENT $20/$100A AGILENT $20/$100A COBRA SP 15/100% ALDILA SP 15/100% ALDILA CB CUSTOM PREFERRED PLAN/GM 74 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit AGD AGE AGF AGH AGI AGJ AGP AGR AGV AGZ AHA AHC AHD AHG AHH AHJ AHL AHN AHT AHX AHZ AI1 AI2 AIC AIJ AIW AIZ AJA AJJ AJN AJS AJT AJU AJZ AKA AKF AKH AKJ AKK AKL AKV AKX AKZ AL1 AL2 AL3 AL4 AL5 AL6 AL7 Plan / Benefit Description SV 10/100% AMGEN 07 SV 15/250A ADMSTFF 07 SV 10/100% AMGEN 07 CB SV 10/100% AMGEN 07 AB AGILENT $20 GRP RET PLAN AGILENT $20/$100A AB SV 15/250A ABC 06 CB 10/20V ACU/CHIRO 07 10/40V ACU/CHIRO 07 CUSTOM PREFERRED/GM/COBRA SV 20-40/500D ADP 05 BEAVERTON HOSPITAL CAP ALAMEDA CLSC I W/HI OP DDS SV 20/250A ASCENT 07 AB MCC 1 ALAMEDA HIGH SH07 SV 10/100% ABC APPREN 05AB MCC 1 ALAMEDA LOW SH07 MC COMP 1 ALAMEDA SH07 SV 10/100% ABC APPREN 05 SV 20-40/500D ADP 05 AB SV 20-40/500D ADP 05 CB ISUPPLI ISUPPLI BIOLA UNIV. PLAN SV 10-20/100% AIWF SEL AB SV 10-20/100% AIWF SEL BIOLA PLAN COBRA SV 10/100% TENET 06 SV 10/100% TENET 06 AB SV 10/100% ABC 06 AB SP 15/100% ALDILA 06 SP 15/100% ALDILA 06 CB SP 15/100% ALDILA 06 AB SV 10/100% TENET 06 CB SV 10/100% LCKMARTIN 06 SV 10/100% CTY ANHM 07 SV 10/100% C ALAMEDA 06 SV 10/100% LCKMARTIN 06 AB DUMMY SV 10/100% C ALAMEDA 06 CB DUMMY SV 10/100% C ALAMEDA 06 AB SV 10/100% LCKMARTIN 06 CB SH ALAMEDA STD MED SH ALAMEDA STD W/ HI DEN SH ALAMEDA PART B ONLY MED SH ALAMEDA PART B W/ HI DE SH ALAMEDA PLUS PLAN MED SH ALAMEDA PLUS W/ HI DEN SH ALAMEDA PART B PLUS MED 75 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit AL8 ALA ALB ALC ALD ALE ALF ALG ALH ALJ ALK ALM ALP ALT ALW ALX ALY ALZ AM2 AM3 AM4 AM5 AM6 AM7 AM8 AM9 AMA AMB AMC AMD AME AMF AMG AMH AMJ AML AMR AMS AMT AMV AMX AMY AMZ AN2 ANA ANB ANC ANH ANJ ANL Plan / Benefit Description SH ALAMEDA B PLUS & HI DEN ASIAN-L.A./ORANGE BASIC ASIAN-L.A./ORANGE NO PRT A LOCKHEED-HOURLY ALAMEDA CLASSIC I W/OP DDS SP 15/100% ALDILA 05 *** OK TO USE *** KEENAN COMP 1 AMEDA GR07 SV 10/350A HTAU 06 SV 20/250A+20%ABC APP 05AB KEC 1 AMEDA HI GR07 KEC 1 AMEDA LO GR07 SV 15/250A ABC 06 AB SV 20/250A+20%ABC APP 05 SV 20/250A+20%ABC APP 05CB SP 15/100% ALDILA 05 AB SP 15/100% ALDILA 05 CB LOCKHEED-HOURLY COBRA AMGEN $10/100% AMGEN $10/100% COBRA DMR UNION $5/$350A AMR UNION $5/$350A COBRA AMR UNION $10/350A AMR UNION $10/350A COBRA AMR UNION $20/$350A AMR UNION $20/$350A COBRA SH BASIC PLAN ALAMEDA CO. SH BASIC-SAN FRANCI B ONLY MARTIN MARIETTA PLAN SV 5/350A HTAU 06 SV 15/100% C ALAMEDA 06 SV 5/350A HTAU 06 CB SV 10/100% AMGEN ADM CDE-OVR 20 OPMH VISITS SV 10/100% AMGEN AB SV 5/350A HTAU 06 AB AMER MED RESPONSE SV 15/100% C ALAMEDA 06 CB SV 20/250A + 20% ABC 06 CB SV 20-40/80% AI 07 CB SV 15/100% C ALAMEDA 06 AB SV 5/100% AME MED 07 MARTIN MARIETTA PLAN SV 10/100% CTYANHM 06 ASIAN-NO.CAL.BASIC PLAN ASIAN-NO.CAL.NO PART A SV 20/350A HTAU 06 CB SV 10/350A HTAU 06 CB SV 10/100% CTY OF ANAHM AB SV 10/100% AMGEN 06 76 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ANN ANP ANX ANZ AOB AOC AOK AOZ AP2 AP3 AP4 AP5 AP6 AP7 APB APD APE APF APG APJ APK APN APQ APR APS APU APV APW APX APY APZ AQA AQD AQG AQH AQJ AQK AQQ AQT AQV AQX AQY ARB ARC ARH ARJ ARL ARN ARQ ART Plan / Benefit Description SV 10/100% CTY OF ANAHM SV 10/100% CTY OF ANAHM CB SV 10/100% AMGEN 06 AB SV 10/100% AMGEN 06 CB ADM CODE-PAC BELL/OB/GYN ROCKWELL-HOURLY 10/30V 1YR GR-CH07 ROCKWELL-HOURLY COBRA CALPERS MED SH 2002 APW LTD $15/$500A APW LTD $15/$500A COBRA SVA 15/500A APW SVA 15/500A APW CB SVA 15/500A APW 06 AB SP 10/100% AZUSA PU 06 SP 10/100% AZUSA PU 06 CB 5/6V 1YR ACU SH07 10/12V 1YR ACU SH07 5/6V 1YR ACU SH08 SV 15-25/200A ADP AB DUMMY 10/12V 1YR ACU SH08 SP 10/100% AZUSA PAC 07 ADMIN/PREMIUM REVERSAL SPLIT PREMIUM - DUMMY SP $10/100 AZUSA PU DUMMY SVA 15/500A APW 06 SP 10/100% AZUSA PU 06 AB SVA 15/500A APW 06 CB SV 15-25/200A ADP CB SV 10/100% OAKDALE ID 05 SV 10/100% OAKDLE ID 05 CB SV 5/100% AME MED 07 CB SV 20-40/500D ADP 07 SV 10/100% OAKDLE ID 05 AB SP 20/100A AGC 06 SP 10/100% AZUSA PAC 07 CB SV 20/250A + 20% ABC 06 AB SP 20/100A AGC 06 CB SP 20/100A AGC 06 AB SV 5/100% AME MED 07 AB SV 20-30/250A IKON 06 RETAIL CLERK PLAN MCC 2 ALAMEDA HIGH SH07 SV 20-30/250A IKON 06 AB MCC 2 ALAMEDA LOW SH07 MC COMP 2 ALAMEDA SH07 SP 10/100% AZUSA PAC 07 AB ADVANCED REPRODUCTIVE THER 77 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ARU ARW ARX ARY ARZ AS1 AS2 ASA ASC ASE ASF ASG ASH ASJ ASL ASM ASP ASQ AST ASU ASX ASZ AT1 AT2 AT3 AT4 AT5 AT6 AT7 ATA ATB ATC ATD ATH ATJ ATK ATL ATM ATP ATQ ATT ATU ATV ATX ATZ AU2 AU3 AU5 AUA AUJ Plan / Benefit Description SV 15-30/250A ADP 07 SV 15-30/250A ADP 07 CB SV 15-30/250A ADP 07 AB SV 20-30/250A IKON 06 CB RETAIL CLERK PLAN COBRA ALLERGY SERUM (SPECIAL) SMALL GROUP ALLERGY SERUM 1996 SUB AGRMT ALL CHANGES PERS-MED. SH BENEFIT ALLERGY SERUM DCHS $10/P ALLERGY SERUM DCHS $5/NC ALLERGY SERUM DCHS $10/SC SV 10/350A HTAU 06 AB SV 15/250A ADMIN AB SV 5/100% C ALAMEDA 06 ALAMEDA CLASSIC I PERS-MED. SH BENEFIT SH AREA REDUCTION PLAN SV 5/100% C ALAMEDA 06 CB SP $10/100 AZUSA PU CB SV 5/100% C ALAMEDA 06 AB PERS-MED. SH BENEFIT COBRA SV ABC APPRN TRST-HIGH SV ABC APPRN TRST-HIGH CB SV ABC APPRN TRST-APPRN SV ABC APPRN TRST-APPRN CB SV ABC APPRN TRST-LOW SV ABC APPRN TRST-LOW CB ATW-STD SH-WL07 SVA AT&T $10-$15/$100A SVA AT&T $10-$15/$100A CB PREFERRED PLAN SCE RET 10/20V ACU/CH06 SVA 10-15/100A AT&T 06 SVA AT&T $10-$15/$100A AB 15/20V ACU/CH06 SVA 10-15/100A AT&T 06 CB SV 15/100% AGCHWT 06 AB ATW-PLUS SH-WL07 ATW ENHANCED SH08 AT&T ATW-PLUS WL-SH08 ATW-STD WL-SH08 SVA 10-15/100A AT&T 06 AB PREFERRED PLAN SCE RET $20-$25/100% $20-$25/100% COBRA SV $20-$25/100% ARAMARK CB SV 25-30/250A ARAMARK 06 SV $20-$25/100% ARAMARK AB 78 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit AUR AUS AUT AUX AUZ AV1 AV6 AVB AVD AVE AVF AVH AVJ AVL AVN AVV AVX AVY AVZ AWB AWC AWG AWH AWJ AWK AWM AXA AXB AXD AXE AXF AXH AXJ AXR AXW AXZ AYA AYJ AYW AYZ AZ2 AZ3 AZ6 AZA AZC AZG AZJ AZM AZR AZT Plan / Benefit Description U/R MGMT. FEE - ARMSTRONG SV $20-$25/100% ARAMARK SV 10-20/100% AIWF SEL CB SV 25-30/250A ARAMARK 6 AB SV 25-30/250A ARAMARK 6 CB SV 15-20/100A AVON SV 15-20/100A AVON 06 SV 20-30/250A AVAD 08 SV 15-25/200A ADP 07 CB SV 15/250A ADMSTFF 07 CB SV 10/100% CTY ANHM 07 CB MCC ESS ALAMEDA HIGH SH07 SV 15-20/100A AVON AB MCC ESS ALAMEDA LOW SH07 MC COMP ESS ALAMEDA SH07 SV 20-40/80% AI 07 AB SV 15-20/100A AVON 06 AB SV 15-20/100A AVON 06 CB SV 15-20/100A AVON CB SV 20-30/250A AVAD 08 CB SV 20/350A HTAU 06 AB SV 10-20/100D AIW SEL06 SV 20-40/500D ADP 07 CB SVA 15/500A APW AB SV 10-20/100D AIW SEL06 CB SV 10-20/100D AIW SEL06 AB SV 15-25/90% TENET 06 SV 20-30/250A AVAD 08 AB SV 15-25/200A ADP 07 AB SV 15/250A ADMSTFF 07 AB SV 10/100% CTY ANHM 07 AB SV 20-40/500D ADP 07 AB SV 15-25/90% TENET 06 AB SV 20/100% AIR-C&R 06 AB SV 20-40/500A+10% ATT07 SV 15-25/90% TENET 06 CB SV 20-30/100A LHMRTN 06 SV 20-30/100A LHMRTN 06 AB SV 20-40/500A+10% ATT07 CB SV 20-30/100A LHMRTN 06 CB CALPERS MED SH 2002 COBRA ADMINISTAFF $15/$250A CBRA SV 15/250A ADMIN CB NON STD $10/$250 COBRA SV 10-15/150A AMR 06 SV 10/100% AMGEN CB PREFERRED PLAN II AB AMER MED RESPONSE COBRA SV 10-15/150A AMR 06 CB AT&T COBRA 79 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit AZW AZX B0D B0H B0L B0N B1C B1D B1H B1J B1L B1N B1T B1X B1Z B25 B2A B2B B2C B2D B2E B2F B2G B2H B2J B2P B2R B2X B3A B3B B3C B3D B3E B3F B3G B3H B3J B3P B3R B4A B4B B4C B4D B4E B4F B4G B4H B4J B4P B4R Plan / Benefit Description SV 20-40/500A+10% ATT07 AB SV 10-15/150A AMR 06 AB MCC 3 S BERDO DELUXE SH07 MCC 3 S BERDO HIGH SH07 MCC 3 S BERDO LOW SH07 MC COMP 3 S BERDO SH07 NON-STANDARD $2 PLAN MCC ESS S BERDO DELUX SH07 MCC ESS S BERDO HIGH SH07 SP 20/500D BEAUDRY AB MCC ESS S BERDO LOW SH07 MC COMP ESS S BERDO SH07 BUTTE STANDARD PLAN BOEING REP PLAN I COBRA NON-STANDARD $2 PLAN COBRA BEHAVORIAL HEALTH RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO BOEING REP PLAN II COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO 80 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit B50 B5A B5B B5C B5D B5E B5F B5G B5H B5J B5P B5R B6A B6B B6C B6D B6E B6F B6G B6H B6J B6R B7A B7B B7C B7D B7E B7F B7G B7H B7J B7P B7R B8A B8B B8C B8D B8E B8F B8G B8H B8J B8P B8R B9A B9B B9C B9D B9E B9F Plan / Benefit Description BASIC 5 PLAN RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 81 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit B9G B9H B9J B9P B9R BA0 BA1 BAA BAB BAD BAJ BAX BAY BAZ BBA BBB BBC BBD BBE BBF BBG BBJ BBK BBP BBZ BCA BCB BCC BCD BCJ BCK BCT BCX BCY BCZ BDA BDC BDD BDE BDH BDJ BDL BDP BDR BDS BDZ BEA BEB BED BEJ Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO BASIC PLAN INACTIVE BASIC PLAN SV 20/250A PBGH BCTL 06 SV 10/100% BOEING 06 SV 10/100% BOEING 06 CB SV 15/150A BAYER AB SV 10/100% BOEING 06 AB SV 15/150A BAYER SV 15/150A BAYER CB SV 20/250A PBGH BCTL 06 SV 15/250A BOEING 06 SANTA BARBARA CLASSIC I SV 15/250A BOEING 07 S BARBARA CLSC I W/EPO DDS SV 15/250A BOEING 06 CB SV 20-30/250A BP 07 SV 20/250A PBGH BCTL 06 AB SV 15/250A BOEING 06 AB S BARBARA CLSC I W/ODP SV 20/250A PBGH BCTL 06 CB SV 15/150A BAYRCRP 06 SV 10/100% BOEING 06 NOT USED SV 10/100% BOEING 06 CB SV 15/150A BAYRCRP 06 AB $15/$250 BECKMAN CONTRA COSTA - PART B ONLY SV 10/100% BOEING 06 AB SV 15/150A BAYRCRP 06 CB $15/$250 BECKMAN COBRA 0/250A BOEING IAM725 GR 06 SAN BERNARDINO CLASSIC I S BERDO CLSC I W/OP DDS S BERDO CLSC I W/EPO DDS S BERDO CLSC I W/HI OP DDS SP $10 BD BIO PHARMAGIN AB 0 BO IAM 725 NO-AARP GR08 SP $10 BD BIO PHARMAGIN SV 20-40/250A BAC 07 OTHER SO. CA - OPTION DNTL SP $10 BD BIO PHARMAGIN CB SV 15-20/250A BECKMN 06 SV 15/100% BOEING 06 SV 15/100% BOEING 06 CB SV 15-20/250A BECKMN 06 AB 82 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit BER BES BEX BEZ BFA BFB BFE BFG BFH BFJ BFN BFP BFR BFZ BGA BGC BGD BGE BGG BGH BGJ BGP BH2 BH4 BHA BHJ BHZ BJA BJD BJF BJG BJH BJJ BJL BJN BJZ BK1 BK2 BK3 BK4 BK5 BK6 BK7 BKD BKE BKF BKJ BKM BKN BKU Plan / Benefit Description SV 20-40/250A BAC 07 CB S BERDO CLSC ENHANCED SV 15/100% BOEING 06 AB SV 15-20/250A BECKMN 06 CB SV 15/100% BOEING 06 SPA 30/500A BARNEY 06 MCC SAN BARBARA EP SH07 SPA 30/500A BARNEY 06 CB SPA 30/500A BARNEY 06 AB SV 15/100% BOEING 06 AB MC COMP SAN BARBARA SH07 MCC SAN BARBARA PP SH07 SV 20-40/250A BAC 07 AB SV 15/100% BOEING 06 CB SV 25/250A 07 SV 25/250A 07 CB SV 15/250A BOEING 07 CB SV 25/250A 07 AB SV 20-30/250A BP 07 CB SV PBGH $20/$250A SV PBGH $20/$250A AB SV PBGH $20/$250A CB BOEING NA-HRLY $10 GRP RET BOEING HOURLY $15 GRP RET SP 20/250A BARNEY 06 SP 20/250A BARNEY 06 AB SP 20/250A BARNEY 06 CB SV 10/100% BOEING 06 MCC 1 S BERDO DELUXE SH07 SP 30/500A BARNEY 07 SV 20-30/250A BP 07 AB MCC 1 S BERDO HIGH SH07 SV 10/100% BOEING 06 AB MCC 1 S BERDO LOW SH07 MC COMP 1 S BERDO SH07 SV 10/100% BOEING 06 CB SV $30-$40/70% SV $30-$40/70% CB SV $30-$40/70% CAL CB SV $30-$40/70% FED CB DIS SV $30-$40/70% FED CB EXT SV $30-$40/70% CAL CB EXT SV $30-$40/70% CAL CB DIS SV 15/250A BOEING 07 AB SV 15/250A BOEING 07 CB SP 30/500A BARNEY 07 CB SV $30-$40/70% AB SV 15-20/250A BECKMAN KERN - PART B ONLY SV $30-$40/70% USERRA 83 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit BLA BLB BLD BLF BLG BLH BLJ BLL BLN BLZ BM1 BM2 BMA BMB BMC BMD BME BMG BMH BMJ BMR BMS BMX BMY BMZ BNB BNC BNJ BNZ BO1 BO2 BOC BON BP2 BP3 BP4 BP5 BP6 BP7 BP8 BP9 BPA BPC BPD BPE BPF BPG BPH BPJ BPK Plan / Benefit Description LOS ANGELES - PART B ONLY SV 15/100% BOEING 06 MCC 2 S BERDO DELUXE SH07 SP 30/500A BARNEY 07 AB SV 15-20/250A BECKMN 07 MCC 2 S BERDO HIGH SH07 SV 15/100% BOEING 06 AB MCC 2 S BERDO LOW SH07 MC COMP 2 S BERDO SH07 SV 15/100% BOEING 06 CB SP 20/500D BEAUDRY SP 20/500D BEAUDRY CB SV 20-30/250A IBM 06 SV 20-40/500D BEAU 06 SV 15-20/250A BECKMAN CB S BERDO MEDICAL W/OP DDS S BERDO MEDICAL W/EPO DDS SV 15/250A BOEING 07 AB S BERDO MEDICAL W/HI DDS SV 15-20/250A BECKMAN AB SV 20-40/500D BEAU 06 CB SAN BERNARDINO MEDICAL SV 20-30/250A IBM 06 AB SV 20-40/500D BEAU 06 AB SV 20-30/250A IBM 06 CB SP $20 BARNEY & BARNEY SV 15/250A BOEING 07 SP $20 BARNEY & BARNEY AB SP $20 BARNEY & BARNEY CB BOEING REP PLAN I BOEING REP PLAN II ORANGE - PART B ONLY 2006 PART B ONLY PLAN RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 84 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit BPL BPM BPN BPP BPQ BPR BPS BPT BPU BPV BPW BPX BPY BPZ BR2 BR3 BR4 BR5 BR6 BR7 BR8 BR9 BRC BRG BRH BRJ BRS BRZ BS1 BS7 BSA BSC BSD BSE BSG BSL BSM BSR BST BSX BSZ BT1 BT2 BT3 BT4 BT5 BT6 BT7 BT8 BTA Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 2004 PART B ONLY PLAN RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO SV 15/100% BOEING 06 SV 15-20/250A BECKMN 07 CB 15/250A BH 08 DONOT USE SV 15/100% BOEING 06 AB RIVERSIDE - PART B ONLY SV 15/100% BOEING 06 CB $20/$250 BECHTEL GR BARIATRIC SURGERY 06 1996 SUB AGRMT-LEGAL ONLY SOUTH CAL EDISON PLAN SAN DIEGO-I : PART B ONLY SAN BERNARDINO - PART B SAN DIEGO-II : PART B ONLY SAN LUIS OBISPO - PART B SACRAMENTO - PART B ONLY SANTA BARBARA -PART B ONLY SAN MATEO - PART B ONLY SANTA CLARA - PART B ONLY SOUTH CAL EDISON COBRA SH BUTTE STD MED SH BUTTE STD W/ HI DEN SH BUTTE PART B STD MED SH BUTTE PART B W/ HI DEN SH BUTTE PLUS PLAN MED SH BUTTE PLUS W/ HI DEN SH BUTTE PART B PLUS MED SH BUTTE B PLUS W/ HI DEN RESERVED TENET BH 06 85 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit BTD BTG BTH BU1 BU2 BU3 BU4 BU5 BU6 BU7 BU8 BU9 BUA BUB BUC BUD BUE BUF BUG BUH BUI BUJ BUK BUL BUM BUN BVA BVB BVC BVD BVE BVJ BVL BVX BWA BWD BWE BWH BX1 BX2 BX3 BX4 BX5 BX6 BX7 BX8 BX9 BXA BXB BXC Plan / Benefit Description RESERVED TENET BH 06 SV 15-20/250A BECKMN 07 AB NOT IN USE PREFERRED PLAN (BIOLA) RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO SH BUTTE PART B PLUS MED RESERVED FOR RX PPO RESERVED FOR RX PPO BUTTE COUNTY-BASIC PLAN BUTTE COUNTY-PART B ONLY RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO SV $15-$25/$250A BOEING SV $15-$25/$250A BOEING CB SV 15-25/250A BOEI 06 SV 15-25/250A BOEI 06 CB 15/100A BOEING VEBA GR07 SV $15-$25/$250A BOEING AB 15 BO-VEBA NON-AARP GR08 SV 15-25/250A BOEI 06 AB *** OK TO USE *** S BRDO CLSC ENHNCD W/OPDDS S BRDO CLSC ENHNCD W/EPDDS S BRDO CLSC ENHNCD W/HIDDS BAXTER PLAN RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 86 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit BXD BXE BXF BXG BXH BXJ BXK BXL BXM BXN BXP BXR BXS BXT BXU BXV BXW BXX BXY BXZ BYA BYB BYC BYD BYE BYF BYG BYH BYJ BYK BYL BYM BYN BYP BYR BYS BYU BYW BYY BZ0 BZ1 BZ3 BZ4 BZ5 BZ6 BZ7 BZ8 BZ9 BZA BZB Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO ARP MCC S BRBRA PP SH08 ARP MCC S BRBRA SH08 ARP MCC S BRBRA EP SH08 BASIC 5 PLAN COBRA BASIC PLAN (COBRA) RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 87 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit BZC BZD BZE BZG BZH BZJ BZK BZL BZM BZN BZP BZR BZS BZT BZU BZV BZW BZX BZY BZZ C10 C11 C1C C1G C1J C1N C1T C1Y C1Z C20 C22 C27 C2B C2C C2E C2H C2J C2M C2V C2Z C3C C3G C3J C3T C3U C3V C3W C3Z C40 C4C Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO PREFERRED PLAN (BIOLA) RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RG CHIRO CUSTOM CHIRO - RETIREE GOLD CUST STANDARD 3 PLAN II GM SLRY HMO 2001$3 STANDARD 3 PLAN II AB $10G/$25B CONTRA COSTA STANDARD PLAN GM SLRY HMO 2001$3 COBRA STANDARD 3 PLAN COBRA II RETIREE GOLD 200 DENTAL SP 25/250A CREST 06 AB SC 90 ELIGIBILITY ONLY SP 25/250A CREST 06 CB MFP STANDARD 3 PLAN II 15/30V GR-CH06 SV 10/100% CHLDRNS HOSP SV 10/100% CHLDRNS HOSP AB 15/20V ACU/CH07 SV 5/100% SCSVEBA 06 MFP STAND 3 PLAN COBRA II $3 GENERAL MOTORS SV 10/100% CA FLD IRN 06 VEBA $5/100% AB CONTRA COSTA PLUS PLAN SV 10/100% CA FLD IRN 06AB SV 5/100% SCSVEBA 06 SV 10/100% CA FLD IRN 06AB $3 GENERAL MOTORS RG CENTURY DENTAL 400 N CA NOT USED 88 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit C4H C4J C4P C4Q C4R C4T C4U C4Z C50 C5C C5F C5G C5H C5J C5L C5T C5V C5W C5X C63 C64 C65 C6A C6H C6J C6L C6T C6W C6X C6Z C73 C74 C75 C7A C7C C7E C7F C7G C7H C7J C7K C7L C7M C7N C7P C7S C7T C7U C7W C7Y Plan / Benefit Description SV 5/100% CHLDHSP 05 SV 5/100% CHLDHSP 05 AB SV 15/100% CAMINO MG 07 SV 15/100% CAMINO MG 07 CB SV 15/100% CAMINO MG 07 AB AUNTRA COSTA STD W/OPT DDS 10/12V 1YR GR-CH07 SV 5/100% CHLDHSP 05 CB RETIREE GOLD 550 DENTAL NOT USED 10/30V ACU/30V CHIRO 07 CAREGIVER ENHANCED GR-CG07 ARP MCC S CLARA HI SH08 VEBA $10/100% AB ARP MCC S CLARA LO SH08 CONTRA COSTA STD. W/HI DNT SV 10/100% SCSVEBA 06 ARP MCC S CLARA SH08 ARP MCC S CLARA DLX SH08 KEC C COSTA CG GR07 KEC C COSTA LO CG GR07 KEC C COSTA HI CG GR07 SV 20-40/400D CKE 06 ARP MCC C CSTA HI SH08 CHWSC SIGPOS 100/80/50 AB ARP MCC C CSTA LO SH08 CONTRA COSTA PLUS W/ DENTL ARP MCC C CSTA SH08 SV 20-40/400D CKE 06 AB SV 20-40/400D CKE 06 CB KEC C COSTA CGII GR07 KEC C COSTA LO CGII GR07 KEC C COSTA HI CGII GR07 5/12V 1YR GR-CH07 COLA 2001 HMO $3/100 10/12V 1YR GR-CH07 10/20V 1YR GR-CH07 10/30V 1YR GR-CH07 15/12V 1YR GR-CH07 15/20V 1YR GR-CH07 0/20V 1YR GR-CH07 15/30V 1YR GR-CH07 20/12V 1YR GR-CH07 25/12V 1YR GR-CH07 5/10V 1YR GR-CH07 30/12V 1YR GR-CH07 CONTRA COSTA PLUS W/HI DEN 5/20V 1YR GR-CH07 5/30V 1YR GR-CH07 5/40 1YR GR-CH07 89 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit C7Z C80 C83 C84 C85 CA0 CA1 CA2 CA3 CA4 CA5 CA6 CA7 CA8 CA9 CAA CAB CAC CAD CAE CAF CAG CAH CAI CAJ CAK CAL CAM CAN CAO CAP CAQ CAR CAS CAU CAW CAZ CB0 CB1 CB2 CB3 CB4 CB5 CB6 CB7 CB8 CB9 CBA CBB CBC Plan / Benefit Description COLA 2001 HMO$3/100 COBRA RETIREE GOLD 800 DENTAL KEC C COSTA CGEH GR07 KEC C COSTA LO CGEH GR07 KEC C COSTA HI CGEH GR07 $0 CARPENTERS PLAN $2 $3 $4 $5 $6 $7 $8 $9 $10 $5G/$10B LA MACHINISTS $1 $5G/$5+30%B $5G/10B/OON $10G/$15B $5 $5G/$10B $7 $5 $10 $5 $10 $0 $5G/$10B $10G/$15B $5G/$25B $10G/$30B $10 $10G/$30B LA MACHINISTS COBRA $0 $1 $2 $3 $4 $5 $6 $7 $8 $9 $10 $5G/$10B $5G/$5+30%B 90 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CBD CBE CBF CBG CBH CBI CBJ CBK CBL CBM CBN CBP CBR CBS CBT CBV CBW CBZ CC1 CC2 CC3 CC4 CC5 CC6 CC7 CC8 CCA CCB CCC CCD CCE CCF CCG CCI CCJ CCK CCL CCM CCW CCY CCZ CD0 CD1 CD2 CD3 CD4 CD5 CD6 CD7 CD8 Plan / Benefit Description $6G/$12B SV 15/250A CCEB 05 $5G/$15B SP 25/250A CREST 06 MCC C COSTA HIGH SH07 $5G/$7B SV 15/250A CCEB 05 AB SP 10/100% CBM 07 MCC C COSTA LOW SH07 $3 FLAT MC COMP C COSTA SH07 $10G/$20B $5G/$25B $10G/$30B SP 25/250A CREST BEV 07 COBRA VENDOR PREM ALLOCATE SP 10/100% CHW-B 07 SV 15/250A CCEB 05 CB SH CONTRA COSTA STD MED CONTRA COSTA MED W/ HI DEN SH CONTRA COSTA PART B MED CONTRA COSTA B W/ HI DEN SH CONTRA COSTA PLUS MED CONTRA COSTA PLUS & HI DEN CONTRA COSTA B W/ HI DEN CONTRA COSTA B PL & HI DEN CAL COBRA 10% ADMIN FEE CAL COBRA RETENTION SV $3/$35 COAST CMNTY CB $6G/$12B END C COSTA BASIC W/ NO DE KEENAN COMP C COSTA GR07 0/20V ACU/20V CHIRO 07 SH CONTRA COSTA STD MED SV $3/$35 COAST CMNTY AB KEC C COSTA HI GR07 KEC C COSTA LO GR07 SV 10/100% CHW-A 07 SV 10/100% CCCYO 06 SV 10/100% CCCYO 06 CB SV 10/100% CCCYO 06 AB LIFELINK CD100 1995 LIFELINK-CHEM DEP 100% LIFELINK CD80 SV 10/100% OCEANSD 06 AB SV 10/100% CHW 06 AB SP 10/100% CHW 06 AB SP 10/100% CHW 06 AB SP 10/100% CHW 06 AB LIFELINK-CHEM DEP 80% 91 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CD9 CDA CDB CDC CDD CDE CDF CDG CDH CDJ CDK CDL CDM CDN CDP CDQ CDR CDS CDT CDU CDV CDX CDZ CE2 CE4 CE6 CE8 CE9 CEA CEB CEC CED CEE CEF CEG CEH CEJ CEM CEO CEP CEQ CES CET CEU CEY CEZ CF0 CF1 CF2 CF3 Plan / Benefit Description 10/40V CH 07 SV 15/250A SCHWAB 06 RET.GOLD DENTAL BASIC SV 10/100% CHBRSCHL 05 SV 10/100% CHW 06 SV 10/100% CHBRSCHL 05 CB SP 10/100% CHW 06 SP 10/100% CHW 06 SP 10/100% CHW 06 SV 15/250A SCHWAB 06 AB SP 10/100% CBM 07 CB $5G/$5B SV 10/100% CHW-A 07 CB SV 10/100% OCEANSD 06 CENTRAL CAL DENTAL PLAN SV 10/100% CHW 06 CB SP 10/100% CHW 06 CB STANDARD 10 PLAN (NO FP) SP 10/100% CHW 06 CB SP 10/100% CHW 06 CB SV 10/100% OCEANSD 06 CB SV 10/100% CHBRSCHL 05 AB SV 15/250A SCHWAB 06 CB 5/40V CH 07 5/30V CH 07 5/20V CH 07 10/30V CH 07 14/20V CH 07 SP 10/100% CALLAWAY 05 SVA 20/250A CENTRE 06 SV 15/250A C CONSTN 06 $0G/$0B SV 15/250A C CONSTN 06 CB SVA 20/250A CENTRE 06 CB SV 15/250A C CONSTN 06 AB SVA 20/250A CENTRE 06 AB SP 10/100% CALLAWAY 05 AB SV 10/100% CHW-A 07 AB 15/30V CH 07 C. COSTA CLSC I W/EPO DDS SV 15-25/100A COMCAST07 SV 15-25/100A COMCAST07 CB SP 25/250A CREST BEV 07 CB SV 15-25/100A COMCAST07 AB SP 10/100% CALLAWAY 05 CB SV CKE LOW OPTION CB SR. PLAN SO.CAL CHIRO SR. PLAN PLUS SO.CAL CHIRO SR. PLAN/PLUS CHIRO-NO CAL SR. PLAN PREMIER CHIRO 92 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CF4 CF5 CF6 CF7 CF8 CF9 CFA CFB CFC CFD CFE CFF CFH CFJ CFK CFN CFO CFR CFS CFT CFU CFZ CG3 CG4 CG5 CG6 CG7 CG8 CG9 CGC CGE CGG CGI CGJ CGK CGL CGM CGP CGQ CGR CGS CGT CGU CGV CGX CH0 CH1 CH2 CH3 CH4 Plan / Benefit Description CHIRO - RETIREE GOLD NO CA CHIRO RETIREE GOLD CUSTOM RG PREMIER CUSTOM CHIRO RETIREE GOLD RG CHIRO CUSTOM RG CHIRO CUSTOM RESERVED FOR RX PPO BASIC ONLY - CHIRO CLOSED RX/CENTRAL 1,000 RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO CHIRO HI-OPTION SUPP. SV CKE HIGH OPTION AB SP 10/100% CBM 07 AB CLOSED RX/NORTHERN 1,200 RET.GOLD $3 CO-PAY RT. GOLD CHIRO $0 A-1325 CLOSED RX/SOUTHERN 2,500 RET.GOLD $0 CO-PAY EH790 CLOSED RX/UPR NO.CAL.1,500 SV CKE HIGH OPTION CB SV 10-15/100% CAPTL GRP SV 10-15/100% CAPTL GRP CB 0/20V CH 07 SV CAPITAL 25/30/500A SV CAPITAL 25/30/500A CB 10/20V CH 07 15/20 CH 07 $5G/$5B CAREGIVER ENHANCED-LACERS CAREGIVER-SH GOLD CAREGIVER-SH INDIV SV 10-15/100% CAPTL GRP AB SV 20-40/400A CKE 08 CAREGIVER LITE SH06 $5G/$5B CAREGIVER PROGRAM SP 15/250A CALLAWAY 07 CAREGIVER- RESPITE SH06 CAREGIVER PROGRAM CAREGIVER STD CG-SH08 CAREGIVER-RESPITE CG-SH08 CAREGIVER CG-GR08 CAREGIVER ENHANCED CHIROPRACTIC CARE CHIROCARE 5/40 PLAN CHIROCARE 5/30 PLAN CHIROCARE 5/20 PLAN CHIROCARE 10/30 PLAN 93 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CH5 CH6 CH7 CH8 CH9 CHA CHB CHC CHD CHE CHF CHG CHH CHI CHJ CHM CHO CHP CHQ CHR CHS CHU CHV CHW CHZ CJA CJC CJD CJJ CJK CJL CJM CJS CJV CJW CJX CJY CK1 CK2 CK3 CK4 CK5 CK6 CK7 CKA CKB CKC CKE CKF CKG Plan / Benefit Description CHIROCARE 14/20 PLAN CHIROCARE $5/$1500 PLAN CHIROCARE 50%/$1500 PLAN CHIROCARE 10/20 PLAN CHIROCARE $15/20 VISITS CHIROCARE $15/30 VISITS CHIROCARE $15/30 VISITS CHIROCARE 5/20 PERS CHIROCARE $10/40 VISITS CHIROCARE $15/40VISITS POS SUTTER CHIRO $10/20 VISITS $15/30 GRP RET CHW $10/H CHIROPRACTIC-PLHIC CHIRO $0/20 VISITS CHIROCARE 10/30 PLAN SR PLAN CHIRO CHW $10/P FEDS 10/20V ACU/CHIRO 05 CHIRO-RETIREE $10/12 CHIROCARE 10/30 SMALL GRP 10/12V 1YR SH-CH07 FEDS 10/20V ACU/CHIRO 07 10/12V 1YR CH-SH08 SV 10/100% CHLDRNS HOSP CB SP 10/100% CRYROP 06 SV 10/100% CVSHWT 06 $10G/$15B SP 10/100% CRYROP 06 AB SV 20-40/400A CKE 08 CB SV 10/100% CVSHWT 06 CB SV 10/100% CVSHWT 06 AB SP 10/100% CHW-D 07 SP 10/100% CHW-C 07 SP 10/100% CHW-C 07 CB SP 10/100% CHW-C 07 AB SP 10/100% CRYROP 06 CB SV $10-$30/100% SV $10-$30/100% CB SV $10-$30/100% CAL CB SV $10-$30/100% FED CB DIS SV $10-$30/100% FED CB EXT SV $10-$30/100% CAL CB EXT SV $10-$30/100% CAL CB DIS 10/100A CCSF GR07 SV 25-50/400D CKE 08 SV 15-30/400A CKE 06 CKE RESTAURANTS INC SV CKE HIGH OPTION SV 10/100% SAN BERDO 07 94 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CKH CKJ CKK CKL CKN CKP CKS CKU CKX CKY CKZ CLA CLC CLD CLE CLF CLG CLH CLJ CLK CLL CLM CLN CLQ CLS CLT CLU CLW CLY CLZ CM0 CM1 CM2 CM3 CM4 CM5 CM6 CM7 CM8 CM9 CMA CMB CMC CMD CME CMI CMK CMM CMP CMQ Plan / Benefit Description SV 10/100% CHILD HOS 08 SV $10-$30/100% AB SV 20-40/400A CKE 08 AB SV CKE LOW OPTION SV 15-30/400A CKE 06 CB CKE RESTAURANTS INC SP 10/100% CHW-D 07 CB SV $10-$30/100% USERRA SV 15-30/400A CKE 06 AB CKE RESTAURANTS INC COBRA CKE RESTAURANTS INC COBRA SV 5/100% COLA 06 UNIVERSAL 3 PLAN II C. COSTA CLSC I W/OP DDS SV 25-30/500A CGRP 07 SV 25-30/500A CGRP 07 CB SV 3/100% COAST COMM 06 MCC ESS C COSTA HIGH SH07 SV CKE LOW OPTION AB SV 10/100% COLA 08 MCC ESS C COSTA LOW SH07 10/100A CCSF GR07 MC COMP ESS C COSTA SH07 SV 10/100% CHW-B 07 SP 10/100% CHW-D 07 AB SP 25/250A CREST BEV 07 AB ARP MCC S CRUZ PP SH08 ARP MCC S CRUZ SH08 ARP MCC S CRUZ EP SH08 UNIVERSAL 3 PLAN COBRA II LIFELINK CM100 1995 LIFELINK - CHEM/MEN 100 LIFELINK CM80 1995 PBGH CD/MH BASE PLAN PBGH MH/CD PLAN 1A PBGH MH/CD PLAN 1B MH/CD IP/100% OP/$5 MH/CD IP/100% OP $10 LIFELINK - CHEM/MEN 80% MH/CD IP/100% OP $15 $10G/$15B SV 25-50/400D CKE 08 CB CRISIS MANAGEMENT PLAN C.COSTA MEDICAL W/OP DDS C.COSTA MEDICAL W/EPO DDS C. COSTA MEDCL W/HIOP DDS SV 10/100% COLA 08 CB CUSTOM MATERIALS ALLOCATIO CONTRA COSTA MEDICAL SV 10/100% CHW-B 07 CB 95 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CMT CNA CNB CNC CND CNE CNF CNG CNH CNJ CNK CNM CNQ CNY CNZ COA COK CP0 CP1 CP2 CP3 CP4 CP5 CP6 CP7 CP8 CPA CPB CPC CPH CPJ CPL CPN CPR CPU CPX CPY CPZ CQA CQD CQE CQF CQH CQL CQN CQU CR0 CR1 CR2 CR3 Plan / Benefit Description CHIROCARE $15/40 VISITS SV 25-30/500A CGRP 06 SV 25-50/400D CKE 08 AB $3 PLAN COUNTY OF LA SV 10-15/100% CGRP 07 0/20V ACU/20V CHIRO 07 SV 25-30/500A CGRP 07 AB SV 10/100% SAN BERDO 07 CB SV 10/100% CHILD HOS 08 CB SV 25-30/500A CGRP 06 AB SV 10/100% COLA 08 AB 15 CTY ANHIM NON-AARP GR08 SV 10/100% CHW-B 07 AB SV 25-30/500A CGRP 06 CB $3 PLAN COUNTY OF LA COBRA 15/100% CITY ANAHEIM GR07 10/30V 1YR GR-CH07 CALPERS $10/20VISITS SH PLUS MED CHIRO CALPERS ACTIVE CHWSC SIGPOS 100/75/50 CHWSC SIGPOS 100/75/50 CBR CUSTOM RX TEAMSTERS $5 CHWSC SIGPOS 100/80/50 CUST $7 RX NRTH COAST TRUS CHWSC SIGPOS 100/80/50 CBR RESERVED PFFS SV 10-20/100% CALPAC 06 $3 PLAN COUNTY OF LA SV 10-15/100% CGRP 07 CB CHWSC SIGPOS 100/75/50 AB SP 10/100% CRYROP 07 SV 10/100% CHW-C 07 CAP RESTORE CODE POS SP 10/100% CHW-A 07 SV 10-20/100% CALPAC 06 AB SV 10-20/100% CALPAC 06 CB $3 PLAN COOUNTY OF LA CBRA SV 20/250A SCHWAB 08 SV 15-25/500A CITIGP 07 SV 10/100% CHW-C 07 AB SV 15-25/500A CITIGP 07 CB SV 15-25/500A CITIGP 07 AB SP 10/100% CRYROP 07 CB SV 10/100% CHW-C 07 CB SP 10/100% CHW-A 07 CB CHIRO $0 OV/20 VISITS P/YR PREFERRED - $0 ER PLAN RET.GOLD $5/20 VISITS GRP RET CHIRO $5/12VISITS 96 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CR4 CR5 CR6 CRA CRB CRC CRE CRG CRJ CRL CRN CRR CRU CRX CRY CRZ CS2 CS3 CS4 CS5 CS9 CSA CSB CSC CSD CSE CSF CSJ CSK CSL CSS CST CSX CSZ CT1 CT2 CT3 CT4 CT5 CT6 CT7 CT8 CTA CTB CTC CTF CTG CTH CTJ CTK Plan / Benefit Description GRP RET CHIRO $10/12VISITS GRP RET CHIRO $15/12VISITS GRP RET CHIRO $20/12VISITS SV 10-15/100% CGRP 06 SV 10/100% CHBRSCHL 06 SV 10/100% CHBRSCHL 06 CB IN ACTIVE DO NOT USE CUSTOM PPO SV 10-15/100% CGRP 06 AB SP 10/100% CRYROP 07 AB SV 10/100% CHBRSCHL 06 AB 10/12V GR-CH07 SP 10/100% CHW-A 07 AB RESERVED FOR RX PPO RESERVED FOR RX PPO SV 10-15/100% CGRP 06 CB CITY OF SAN DIEGO GR 2003 CITY OF SAN DIEGO GR 2004 CHARLES SCHWAB 15/100A CHARLES SCHWAB 15/100A CBR SV $15/$100A C SCHWAB CB SUB AGREEMENT - CUSTOM SV 10/100% SAN BERDO 06 STANDARD 3 PLAN - CUSTOM CITY OF SAN DIEGO SV $15/$100A C SCHWAB SPT 15/35 C S DIEGO 06 SV $15/$100A C SCHWAB AB SV 20/250A+80% COLB 07 SV 10/100% SAN BERDO 06 CB CONTRA COSTA CLASSIC I SV $3/$35 COAST CMNTY SV 10/100% SAN BERDO 06 AB STAND 3 PLAN - CUSTOM CHIROCARE $10/20 VISITS CHIROCARE $15/20 VISITS CHIROCARE $15/30 VISITS CHIROCARE $5/20 VISITS CHIROCARE $5/30 VISITS CHIROCARE $5/40 VISITS CHIROCARE $10/30 VISITS CHIROCARE $14/20 VISITS SH BASIC CONTRA COSTA CO. SH CONTRA COSTA CO. B ONLY SV 15-25/500A CITIGP 06 SPT 15/35 C S DIEGO 06 CB SV 15-25/500A CITIGP 06 CB SV 10/100% CCCYO 05 SV10/100% CCCYO 05 AB SV 20/250A+80% COLB 07 CB 97 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CTT CTW CTX CUA CUB CUF CUG CUH CUK CUW CV2 CV3 CV4 CV5 CV6 CV7 CV8 CV9 CVA CVB CVC CVE CVF CVG CVH CVJ CVK CVL CVM CVN CVP CVQ CVR CVS CVU CVV CVW CVX CVY CWA CWB CWC CWE CWF CWG CWH CWQ CWW CX7 CX8 Plan / Benefit Description SV10/100% CCCYO 05 CB SP 10/100% CHW-B 07 CB SV 15-25/500A CITIGP 06 AB $5G/$20B $10G/$25B SPT 15/35 C S DIEGO 06 AB SV 3/100% COAST COMM 06 CB SV 10-15/100% CGRP 07 AB SV 20/250A+80% COLB 07 AB 15/20V ACU/CHIRO 07 VEBA $5/100% VEBA $5/100% COBRA VEBA $10/100% VEBA $10/100% COBRA SV 15/100% VERIZON COMM CB SV 10/250A VNTRA 06 SV 10/250A VNTRA 06 CB SV 10/250A VNTRA 06 AB HI-OPTION VISION $9 COPAY HI-OPTION VISION $15 COPAY HI-OPTION VISION $20 COPAY SV 5/100% SCSVEBA 06 CB SV 10/100% SCSVEBA 06 CB SV 5/100% SCSVEBA 06 CB SV 5/100% SCSVEBA 06 AB SV 15/100% VERIZON COMM AB SV 10/100% SCSVEBA 06 AB SV 5/100% CVSHWT 06 SV 20/100% CVS 06 SV 5/100% CVSHWT 06 CB SV 5/100% CVSHWT 06 AB SV 0/100% CVS 06 SV 20/100% CVS 06 CB SV 0/100% CVS 06 CB SV 20/100% CVS 06 AB SV 0/100% CVS 06 AB SV 15/100% VERIZON COMM SV 15/100% VERIZON 06 SV 5/100% SCSVEBA 06 AB SP 15/100% CSM 07 SP 15/100% CSM 07 CB SP 15/100% CSM 07 AB SV 10/100% COLB 07 SVA 15/100% CHU VSTA 08 SV 10/100% SAN BERDO 07 AB C. COSTA CLSC I W/HIOP DDS SP 15/250A CALLAWAY 07 CB SP 10/100% CHW-B 07 AB SV 15/100% VERIZON 06 CB 25/12V UFCW CH-GR08 98 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit CXA CXB CXC CXD CXE CXF CXG CXH CXJ CXX CXZ CYA CYE CYF CYG CYH CYJ CYK CYL CYM CYN CYO CYQ CYW CYX CYY CYZ CZ1 CZ2 CZH CZJ CZP CZS D00 D01 D02 D0C D0D D10 D1C D1D D1E D1F D1G D1J D1P D1R D1S D1W D1Y Plan / Benefit Description SV 20/250A SCHWAB 08 CB SV 10/250A OCEANSD 07 SV 10/250A OCEANSD 07 CB SV 10/250A OCEANSD 07 AB SV 10/100% COLB 07 CB SVA 15/100% CHU VSTA 08 CB SV 3/100% COAST COMM 06 AB 20/30V CH 08 SV 15/100% VERIZON 06 AB SV 20/250A SCS VEBA 06 AB SV 20/250A SCS VEBA 06 CB SV 20/250A SCHWAB 08 AB SV 10/100% COLB 07 AB SVA 15/100% CHU VSTA 08 AB SV 10/100% CHW-D 07 SV 10/100% CHILD HOS 08 AB SV CATH CHARITIES CYO AB SV 10/100% CHW-D 07 CB 15/40V CH 07 SV 10/100% CHW-D 07 AB ENTERED IN ERROR - SEE CYH SV CATH CHARITIES CYO SP 15/250A CALLAWAY 07 AB SV 30/500A CCCYO 06 SV 30/500A CCCYO 06 CB SV 30/500A CCCYO 06 AB SV CATH CHARITIES CYO CB 04RPENTERS PLAN (COBRA) CALPERS ACTIVE COBRA CHW $10/H COBRA CHW $10/H AB CHW $10/P COBRA STAND 10 PLAN COBRA/NO FP DURABLE MED EQUIP $0 DURABLE MED. EQUIP. (TRW) DME COUNTY OF LA FEDERAL EMPLOYEES 1-99 FEHB DOD EMPLOYEES 2000 DME 10% STANDARD 5 PLAN II ELITE 5 FED CBR DISABLED ELITE 5 FED CBR EXTENDED ELITE 5 CAL CBR EXTENDED ELITE 5 CAL CBR DISABLED STANDARD 5 PLAN II AB STANDARD 5 PLAN - POS ELITE 5 CAL COBRA ELITE 5 ELITE 5 COBRA STANDARD 5 PLAN - POS CBR 99 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit D1Z D20 D2C D2D D2E D2F D2G D2J D2P D2R D2S D2W D2Y D2Z D3C D3P D3Y D3Z D4C D4E D4F D4G D4H D4I D4J D4K D4P D4Q D4X D4Y D4Z D50 D5C D5P D5Y D5Z D6A D6B D6C D6D D6P D6V D6Y D6Z D7C D7P D7Y D7Z D8A D8B Plan / Benefit Description STANDARD 5 PLAN COBRA II DURABLE MED EQUIP 20% MFP STANDARD 5 PLAN II PREMIER 5 FED CBR DISABLED PREMIER 5 FED CBR EXTENDED PREMIER 5 CAL CBR EXTENDED PREMIER 5 CAL CBR DISABLED MFP STANDARD 5 PLAN II AB MFP STD 5 - POS PREMIER 5 PLAN CAL CBRA PREMIER 5 PLAN PREMIER 5 PLAN CBRA MFP STD 5 - POS COBRA MFP STAND 5 PLAN COBRA II MODIFIED STANDARD 5 PLAN STANDARD 5-CUSTOM STANDARD 5-CUSTOM COBRA MODIFIED STANDARD 5 COBRA MFP 5/1000-SJHS 469 (EPO) GR-DN07 SOUTHERN BASIC GR-DN07 CENTRAL BASIC GR-DN07 NORTHERN BASIC GR-DN07 SOUTHERN HIGH GR-DN07 CENTRAL HIGH GR-DN07 NORTHERN HIGH GR-DN07 NON-STANDARD $5 POS PLAN 466 (PPO) GR-DN07 DELUXE OPTION GR-DN07 NON-STANDARD $5 POS CBRA MFP 5/1000-SJHS COBRA DME $50 / $2500 UNIVERSITY OF CALIFORNIA BENEFIT ALLIANCE $5POS-A BENEFIT ALLIANCE $5POS CBR UNIVERISTY OF CAL. COBRA HI-OP DNTL SOTHRN CALIF 06 HI-OP DNTL NORTHRN CAL 06 STANDARD 5-CUSTOM HI-OP DENTAL CENTRAL CA 06 COLA 2001 POS 100/85/60 DENTAL - VISION GR06 COLA 2001POS 100/85/60 CB STANDARD 5-CUSTOM COBRA BENEFITS ALLIANCE PLAN A MFP STD 10 - POS MFP STD 10 - POS COBRA BENEFITS ALLIANCE COBRA DELUXE OPTION DN-SH08 PREVENTIVE DN-SH08 100 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit D8C D8E D8N D8Q D8R D8S D8T D8U D8V D8Y D8Z D9C D9Z DA1 DA2 DAC DAZ DB1 DB2 DBA DBC DBE DBF DBG DBJ DBZ DC1 DC2 DCC DCJ DCN DCP DCR DCS DCX DCZ DD1 DD2 DD3 DD4 DDC DDD DDE DDF DDH DDJ DDK DDL DDP DDY Plan / Benefit Description MCDONNELL DOUGLAS EPO (469) DENTAL DN-SH08 HI-OP CE CAL DN-SH08 CENTRAL CAL DN-SH08 PPO (466) DENTAL DN-SH08 HI-OP SO CAL DN-SH08 SOUTHERN CAL DN-GR08 HI-OP NO CAL DN-SH08 NORTHERN CAL DN-SH08 EC P&C 200 1YR DN-SH08 MCDONNELL DOUGLAS COBRA PBGH 5 PBGH 5 COBRA SUTTER HEALTH $5 HMO SUTTER HEALTH $5 HMO COBRA AT&T PLAN AT&T PLAN COBRA $5 HMO 2000 SER $5 HMO 2000 SER CBRA 100%/70% DISCOUNT GR-DN07 US BORAX-HPA SV 25/100% DUCOMMUN 07 SVA 15-30/250A DELUX 07 SV 10/100% DCHS 07 $5 HMO 2000 SER AB US BORAX-HPA NON-STD HMO $5 NON-STD HMO $5 COBRA STANDARD $5/$25 PLAN DCHS SOUTHERN CALIF AB DCHS NORTHERN CALIF DCHS POS SO CAL POS DEDUCTIBLE CREDIT DCHS SOUTHERN CALIF DCHS POS SO CAL AB STANDARD $5/$25 PLAN COBRA SAN DIEGO 5 HMO ACTIVE SAN DIEGO 5 HMO ACTIVE CBR SAN DIEGO 10 HMO ACTIVE SAN DIEGO 10 HMO ACT CBR FEDERAL EMPLOYEES 1993 SP 10/100% DCHS NC 06 S DIEGO MEDICAL W/EPO DDS SP 10/100% DCHS 07 S DIEGO MEDICAL W/HIOP DDS SP 10/100% DCHS NC 06 AB SP 10/100% DCHS NC 06 CB S DIEGO MEDICAL W/OP DDS DEC PLAN CODE NEVER USED DEC PLAN CODE NEVER USED 101 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit DE1 DE2 DE3 DE4 DEC DEF DEH DEJ DEK DF1 DF2 DFA DFB DFC DFE DFF DFJ DFZ DGC DGE DGZ DH2 DH3 DH4 DH5 DH6 DH7 DH8 DH9 DHA DHB DHC DHD DHE DHG DHJ DHM DHP DHR DHS DHW DIR DJB DJC DJJ DJP DJZ DK1 DK2 DK3 Plan / Benefit Description SAN DIEGO 5 HMO EA RET SAN DIEGO 5 HMO EA RET CBR SAN DIEGO 10 HMO EA RET SAN DIEGO 10 HMO EA RET CB SV-S 15-30/250D DE17 06 SV 25/100% DUCOMMUN 07 CB SV-S 15-30/250D DE17 06 CB SV 5/100% 06 AB SV-S 15-30/250D DE17 06 AB NON STD CUSTOM $5 HMO NON STD CUSTOM $5 HMO CBRA SV 10/100% DELPHI 06 SV 10/100% DELPHI 06 CB FRESNO COUNTY PLAN II SV 5/100% DCHS 07 SVA 15-30/250A DELUX 07 CB SV 10/100% DELPHI 06 AB FRESNO COUNTY PLAN CBRA II GTE BENEFITS PLAN SP 10/100% DCHS 07 GTE BENEFITS PLAN COBRA SVA 40-60/2-DEDUC SG06 CB SVA 40-60/2-DEDUC SG06 AB SVA 40-60/2-DEDUC SG06 CC SVA 40-60/2-DEDUC SG06 FD SVA 40-60/2-DEDUC SG06 FD SVA 40-60/2-DEDUC SG06 CD SVA 40-60/2-DEDUC SG06 CE SVA 40-60/2-DEDUC SG06 US SV 15/100% DELPHI 06 SR PLAN BASIC DENTAL-SOCAL FEDERAL EMPLOYEES SV 15/100% DELPHI 06 CB SV 5/100% DCHS 07 CB SR GOLD DENTAL SO CAL SV 15/100% DELPHI 06 AB SVA 40-60/2-DEDUC SG06 SH BASIC DENTAL PREFERRED PLAN/HIPC CA CBR PREFERRED PLAN HIPC PREFERRED PLAN HIPC COBRA DUMMY-USED FOR VRU CODING SV 5/100% DCHS NC 06 BECHTEL PLAN SV 5/100% DCHS NC 06 AB SV 5/100% DCHS NC 06 CB BECHTEL PLAN COBRA SV $10/$500D SV $10/$500D CB SV $10/$500D CAL CB 102 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit DK4 DK5 DK6 DK7 DKC DKE DKF DKG DKJ DKU DKZ DL1 DL2 DL3 DLC DLJ DLP DLS DLW DLY DLZ DM2 DM5 DMA DMC DMD DME DMF DMG DMI DMJ DMK DMP DMR DMY DMZ DN2 DN3 DNA DNB DNC DNE DNG DNP DNS DNT DNY DNZ DOC DOJ Plan / Benefit Description SV $10/$500D FED CB DIS SV $10/$500D FED CB EXT SV $10/$500D CAL CB EXT SV $10/$500D CAL CB DIS PBGH 5 SP 10/100% DCHS 07 CB SP 10/100% DCHS 07 CB SV 10/100% DCHS 07 CB SV $10/$500D AB SV $10/$500D USERRA PBGH 5 (COBRA) STANDARD - $0 ER PLAN COUNTY OF LOS ANGELES COUNTY OF LOS ANGELES CBRA UNIVERSAL 5 PLAN II COUNTY OF LOS ANGELES AB $5 POS COUNTY OF LA HIGH OPTION PLAN HIGH OPTION PLAN - COBRA $5 POS COUNTY OF LA COBRA UNIVERSAL 5 PLAN COBRA II DME $50 / $2000 DME $50/$5000 SV 10/100% DCHS SC 06 PBGH 5 2-DEDUC DM06 DURABLE MED EQUIP $50 DME $0/$5000 SAN DIEGO MEDICAL $50/$2000 DME INDIVIDUAL SV 10/100% DCHS SC 06 AB SV 10/100% DCHS SC 06 CB $5 POS COUNTYOF LA $5 BASIC DENTAL DN-GR08 $5 POS COUNTY OF LA COBRA PBGH 5 - COBRA PPO 460 GRP BILLED - GR PPO 462 INDIV BILLED -GR PREVENTIVE SH-DN07 PACIFICARE DENTAL - BASIC HPA PLAN 02 EVERCARE $5 SH-DN07 SR BASIC DENTAL NO CAL PACIFICARE DENTAL PREPAID SR PLUS DENTAL NO CAL DENTAL PLAN DELUXE OPTION SH-DN07 HPA PLAN 02 COBRA $5 EDISON INTERNATIONAL $5 EDISON INTERNATIONAL AB 103 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit DOY DOZ DP1 DPA DPB DPC DPM DPN DPP DPS DPW DPY DPZ DQ6 DQC DQE DQZ DR2 DRC DRD DRE DRG DRH DRJ DRP DRR DRY DRZ DS1 DS2 DS3 DS4 DS5 DS6 DS7 DSA DSB DSC DSE DSF DSG DSJ DSL DSM DSP DSS DSU DSY DSZ DT0 Plan / Benefit Description $5 EDISON INTERNATIONAL CB DUMMY DEPENDENT LIFE BENE DOMESTIC PARTNER AMENDMENT DOMESTIC PARTNR COBRA-LIKE PAC BELL PLAN DOMESTIC PARTNER MID/LARGE DCHS POS NO CAL SR PREMIER DENTAL NO CAL STANDARD 5 PLAN (DEC/POS) DISABILITY PREMIUM WAIVER DCHS POS NO CAL COBRA PAC BELL PLAN COBRA SH EPO (469) DENTAL 06 DIGITAL EQUIP CO. PLAN SV 5/100% DCHS 07 AB DIGITAL EQUIP CO. COBRA PDV DENTAL PLAN 130 GR TRW PLAN SP 10/100% DCHS SC 06 SP 10/100% DCHS 07 AB BASIC DENTAL RETIREE GOLD SP 10/100% DCHS SC 06 CB SP 10/100% DCHS SC 06 AB REDLANDS USD $5 POS 10-20/200A DERP GR07 REDLANDS USD $5 POS CBRA TRW PLAN COBRA HMO 5 PLAN HMO 5 PLAN CBRA HMO 5 PLAN CAL CBRA HMO 5 FED CBR DISABLED HMO 5 FED CBR EXTENDED HMO 5 CAL CBR EXTENDED HMO 5 CAL CBR DISABLED SV $5/100% SV $5/100% CB PERS PLAN SV 5/100% 06 SV 5/100% 06 CB SV 10/100% DCHS 07 AB SV $5/100% AB DOWNEY SAVING & LOAN PREM RIVERSIDE CLASSIC I STD. 5 POS - CUSTOM SR SILVER DENTAL SO CAL HMO 5 PLAN USERRA STD 5 POS-CUSTOM COBRA PERS PLAN COBRA DENTAL ONLY (INDEMNITY) 104 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit DT1 DT2 DT3 DT6 DTA DTC DTF DTJ DTO DTX DTY DTZ DUC DUF DUZ DVC DVD DVE DVF DVH DVS DVZ DWC DWD DWE DWH DWZ DXC DXF DXG DXZ DYB DYC DYD DYE DYF DYG DYP DZ1 DZC DZF DZG DZN DZP DZS DZZ E0C E10 E11 E12 Plan / Benefit Description CDHP DENTAL PLAN 390 CDHP DENTAL PLAN 490 CDHP DENTAL PLAN 590 SH PPO (466) DENTAL 06 SV 20/200A DIRECTV 06 G-TEL PLAN SVA 15-30/250A DELUX 07 AB SV 20/200A DIRECTV 06 AB DENTAL ONLY (INDEMNITY) DENTAL ONLY (INDEMNITY) SV 20/200A DIRECTV 06 CB G-TEL PLAN COBRA HMO 5 SPM ANAHEIM DISABLED SP 10/100% DCHS 07 AB CUSTOM HMO 5 SPM ANAHEIMCB UNIV OF CAL PLAN SAN DIEGO VALUE W/OP DDS SAN DIEGO VALUE W/EPO DDS SV 25/100% DUCOMMUN 07 AB SAN DIEGO VALUE W/HIOP DDS SAN DIEGO VALUE UNIV OF CAL PLAN FHHN-HIGH OPTION PLAN RIVERSIDE CLSC I W/OP DDS RIVERSIDE CLSC I W/EPO DDS RIVERSIDE CLSC I W/HI DDS FHHN HIGH OPTION (COBRA) $5 HMO AZUSA USD SV 10/100% 1500D 06 SV 20-40/250A 500D 06 $5 HMO AZUSA USD COBRA SV 20-40/80% DRW FRD 07 COUNTY OF FRESNO-RETIREES SV 20-40/80% DRW FRD 07 CB SV 20-40/80% DRW FRD 07 AB SV 10/100% 1500D 06 CB SV 20-40/250A 500D 06 CB DCHS POS SO CAL COBRA STANDARD-$0 ER PLAN COBRA NON STANDARD $5 PLAN SV 10/100% 1500D 06 AB SV 20-40/250A 500D 06 AB DCHS NORTHERN CALIF COBRA STANDARD 5 (COBRA/DEC/POS) DCHS SOUTHERN CALIF COBRA NON STANDARD $5 PLAN CBRA EVERCARE ALAMEDA IH SH07 SR PLAN RX-MARIN SR PLUS RX-MARIN SR PREMIER RX-MARIN 105 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit E13 E14 E15 E16 E17 E18 E19 E1C E1L E20 E21 E22 E23 E24 E25 E26 E2A E2C E3A E3C E3E E3J E3T E4C E5C E6C E7C E8C E8F E8G E8H E8J E8K E8L E8M E8N E8P E8Q E8R E8S E8T E8U E8V E8W E8X E8Y E8Z E9C EA2 EA3 Plan / Benefit Description RETIREE GOLD RX SO RETIREE GOLD RX RG PREMIER RX RETIREE GOLD RX 5/UNLIMITE RETIREE GOLD RX 4/UNLIMITE RETIREE GOLD RX 3G/6B NOMX RETIRE GLD RX 1/NOMAX-PERS EVERCARE ALAMEDA DH SH07 EL DORADO STANDARD PLAN RETIREE GOLD RX 6/2000 MAX RET.GOLD RX 5 CO-PAY/UNLIM RET.GOLD $0 CO-PAY/UNLIM. RETIREE GOLD RX 6/NO MAX CUSTOM RX RETIREE GOLD RX CUSTOM-MCDONNELL RETIRE RET.GOLD $6 CO-PAY/UNLIM. SV 25/100% 06 EVERCARE CC DH SH07 SV 25/100% 06 CB EVERCARE CC IH SH07 SV 10/100% L3 ELCTRN 05 CB SV 10/100% L3 ELCTRN 05 AB SV 10/100% L3 ELECTRON 05 EVERCARE LA DH SH07 EVERCARE ORANGE DH SH07 EVERCARE RVSIDE DH SH07 EVERCARE SB DH SH07 EVERCARE SF DH SH07 EVERCARE SD MH-S SH08 EVERCARE SD MH SH08 EVERCARE ALMDA MH SH08 EVERCARE CC MH SH08 EVERCARE SF MH SH08 EVERCARE ALMDA DH SH08 EVERCARE CC DH SH08 EVERCARE SF DH SH08 EVERCARE ALMDA IH SH08 EVERCARE CC IH SH08 EVERCARE SF IH SH08 EVERCARE LA MH SH08 EVERCARE LA DH SH08 EVERCARE OR MH SH08 EVERCARE ORANGE DH SH08 EVERCARE RVSIDE DH SH08 EVERCARE RVSIDE MH SH08 EVERCARE S BERDO DH SH08 EVERCARE S BERDO MH SH08 EVERCARE SF IH SH07 SV 25/100% 06 AB EAP PLAN A 106 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit EA5 EA8 EAA EAD EAH EAI EAJ EAL EAN EAO EAP EAZ EB3 EB5 EB8 EBA EBB EBC EBD EBE EBF EBG EBJ EBO EBP EBT EBU EBY EBZ EC3 EC5 EC8 ECA ECB ECC ECD ECE ECH ECJ ECL ECO ECP ECS ECZ ED1 ED2 ED3 ED4 ED5 ED6 Plan / Benefit Description EAP PLAN A EAP PLAN A SV 20/100A EXPERIAN 06 SH ALAMEDA - ENDORSED MCC ESS S DIEGO HIGH SH07 SV 20/250A EPSON SV 20/250A EPSON AB MCC ESS S DIEGO LOW SH07 MC COMP ESS S DIEGO SH07 EVERCARE LA DH-D SH08 EAP SERVICES/ LIFELINK SV 20/250A EPSON CB EAP PLAN B EAP PLAN B EAP PLAN B ENDRSD RETRE -SLO/SB PRT B ENDRSD RETRE-BAY AREA PRTB SV 0/100% EBDD 06 SV 0/100% E B DRAYAGE SH BUTTE - ENDORSED SV 0/100% EBDD 06 CB SV 0/100% EBDD 06 AB SV 0/100% E B DRAYAGE AB EVERCARE ORANGE DH-D SH08 EMPLOYER SPONSERED PLAN ENDRSD RETRE BUTTE PART B ENDRSD RETIREE BUTTE ENDRSD RETRE-BAY AREA SV 0/100% E B DRAYAGE CB EAP PLAN C EAP PLAN C EAP PLAN C ENDRSD RETREE -CENTRAL ENDRSD RETRE-CENTRAL PRT B SH CONTRA COSTA - ENDORSED SAN DIEGO CLSC I W/OP DDS SAN DIEGO CLSC I W/EPO DDS SAN DIEGO CLSC I W/HI DDS SV 20/100A EXPERIAN 06 AB END RET SANTA CLARA B-ONLY EVERCARE RVSIDE DH-D SH08 10/100% EDISON FLEX GR06 SAN DIEGO CLASSIC I SV 20/100A EXPERIAN 06 CB SCE PLAN $2 OV $25 ER ALAMEDA II STANDARD PLAN 0/100% EDISION PRIME GR06 ALAMEDA II PLUS PLAN ALAMEDA II STD W/OPT DDS ALAMEDA II STD W/HI OP DDS 107 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ED7 ED8 EDA EDB EDC EDD EDE EDF EDG EDH EDJ EDK EDL EDM EDN EDO EDZ EEA EEB EED EEF EEJ EEO EET EF3 EF5 EF9 EFA EFB EFH EFJ EFL EFN EFO EFR EFZ EG1 EG3 EG5 EG6 EG9 EGA EGB EGC EGD EGE EGF EGG EGH EGJ Plan / Benefit Description ALAMDA II PLS PLN W/OP DDS ALAMDA II PLS PLN W/HI DDS ENDORSED RETIREE EL DORADO ENDRSD RETRE SAC/EL PART B SP 10/100% 35ER EDISON SP 10/100% 35ER EDISON CB SP 0/100% EDISON SP 0/100% EDISON CB SV 20-40/50% SV 20-40/50% CB SP 10/100% 35ER EDISON AB SV 15/250A EDCO DPSL 06 SV 15/250A EDCO DPSL 06 CB SV 15/250A EDCO DPSL 06 AB 0/100% EDISON-P AARP GR08 EVERCARE S BERDO DH-D SH08 SCE PLAN $2OV $25ER COBRA SV 11/100% EDISON 08 ENDRSD KERN CO. B ONLY SH EL DORADO - ENDORSED SV 10/100% EDISON 07 SP 0/100% EDISON AB EVERCARE SF DH-D SH08 PC HR EXPRESS MCC 1 S DIEGO LO-PL SH07 MCC 1 S DIEGO HI-PL SH07 MCC 1 S DIEGO PLUS SH07 SV 20/250A EPSNAMR 06 ENDR RET SAN FRAN B-ONLY MCC 1 S DIEGO HIGH SH07 SV 20/250A EPSNAMR 06 AB MCC 1 S DIEGO LOW SH07 MC COMP 1 SAN DIEGO SH07 EVERCARE CC DH-D SH08 SH FRESNO - ENDORSED SV 20/250A EPSNAMR 06 CB EAP - CUSTOM PLAN GATE MCC 3 S DIEGO LO-PL SH07 MCC 3 S DIEGO HI-PL SH07 SV 20/100% EGUSD 06 MCC 3 S DIEGO PLUS SH07 ELK GROVE USD $20 GR ENDRSD RETIREE B ONLY S.D. SV 20/250A EPSON 07 SV 20-40/600D ELGAR 07 SV 20/250A EPSON 07 CB SV 10/100% EDISON 07 CB SV 20/250A EPSON 07 AB MCC 3 S DIEGO HIGH SH07 SV 20-40/50% AB 108 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit EGL EGN EGO EGX EGZ EHA EHJ EHO EHZ EIA EIB EIM EIO EJ3 EJ5 EJ9 EJA EJB EJH EJL EJN EJO EKB EKD EKF EKN EKO EKV EL1 EL2 EL3 EL4 EL5 EL6 EL7 EL8 ELA ELB ELD ELE ELJ ELO ELZ EM2 EM3 EM4 EM5 EM6 EM7 EM8 Plan / Benefit Description MCC 3 S DIEGO LOW SH07 MC COMP 3 SAN DIEGO SH07 EVERCARE ALMDA DH-D SH08 SV 20/100% EGUSD 06 AB SV 20/100% EGUSD 06 CB SV 0/100% CA-EDISON 06 SV 0/100% CA-EDISON 06 AB EVERCARE LA MH-D SH08 SV 0/100% CA-EDISON 06 CB ENDRSD RETIREE -IMPERIAL ENDRSD RETIREE -IMPER PART SH IMPERIAL - ENDORESED EVERCARE OR MH-D SH08 MCC 2 S DIEGO LO-PL SH07 MCC 2 S DIEGO HI-PL SH07 MCC 2 S DIEGO PLUS SH07 SV 11/100% EDISON 08 CB ENDR RET SAN JOAQ B-0NLY MCC 2 S DIEGO HIGH SH07 MCC 2 S DIEGO LOW SH07 MC COMP 2 SAN DIEGO SH07 EVERCARE S BERDO MH- SH08 ENDRSD RETRE KERN/VENT B SV 20-40/600D ELGAR 07 CB SV 10/100% EDISON 07 AB SH KERN - ENDORSED EVERCARE RVSIDE MH-D SH08 ENDRSD RETIREE -KERN/VENT SH EL DORADO STD MED SH EL DORADO STD W/ HI DEN EL DORADO PART B STD MED EL DORADO PART B W/ HI DEN SH EL DORADO PLUS PLAN MED EL DORADO PLUS W/ HI DEN EL DORADO B PLUS W/ HI DEN EL DORADO B PLUS W/ HI DEN SH LOS ANGELES - ENDORSED ENDRS RET. ELDORADO B ONLY SV 20-40/600D ELGAR 07 AB SV 15-30/600D ELGR 06 SV 15-30/600D ELGR 06 AB EVERCARE ALMDA MH-D SH08 SV 15-30/600D ELGR 06 CB SVA 10/500D SG05 SVA 10/500D SG05 CB SVA 10/500D SG05 CAL CB SVA 10/500D SG05 FED CBDIS SVA 10/500D SG05 FED CBEXT SVA 10/500D SG05 CAL CBEXT SVA 10/500D SG05 CAL CBDIS 109 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit EMA EMB EMC EMD EMJ EMN EMO EMR EMU EMY EN2 EN3 EN4 EN5 EN6 EN7 EN8 ENA ENB ENC END ENE ENH ENJ ENO ENP ENS ENU ENX ENZ EOB EOC EON EOO EP1 EPA EPB EPC EPE EPO EPS EQE ER1 ER4 ER5 ER6 ER7 ER8 ERB ERE Plan / Benefit Description ENDORSED RETIREE MARIN ENDRSD RETRE MONTRY PART B SH MERCED - ENDORSED SH MADERA - ENDORSED SVA 10/500D SG05 AB SH MARIN - ENDORSED EVERCARE CC MH-D SH08 ENDRSD RETIRE MARIN PRT B SVA 10/500D SG05 USERRA ENDRSD RETRE MONTEREY SVA 35/600D SG05 SVA 35/600D SG05 CB SVA 35/600D SG05 CC SVA 35/600D SG05 FD SVA 35/600D SG05 FE SVA 35/600D SG05 CE SVA 35/600D SG05 CD ENDRSD RETRE NAPA ENDRSD RETIREE NAPA PART B SV 10/100% EDISON 06 S DIGO CLSC ENHNCD W/OPDDS S DGO CLSC ENHNCD W/EPODDS S DGO CLSC ENHNCD W/HI DDS SVA 35/600D SG05 AB EVERCARE SF MH-D SH08 SH NAPA - ENDORSED S DIEGO CLASSIC ENHANCED SVA 35/600D SG05 US SV 10/100% EDISON 06 AB SV 10/100% EDISON 06 CB ENDRSD ORANGE CO B ONLY SH ORANGE - ENDORSED END RET SONOMA B-ONLY EVERCARE SD MH-S-D SH08 EAP CUSTOM PLAN SV 11/100% EDISON 08 AB ENDRSD RETRE PLAC/SJQ PART SH PLACER - ENDORSED SV 20-40/50% 07 EVERCARE SD MH-D SH08 ENDRSD RETREE-PLACR S.JQN SV 20-40/50% 07 CB ORANGE PREMIER STD PLAN ORANGE PREMIER PLUS PLAN ORANGE PREM STD W/OPT DDS ORANGE PREM STD W/HIOP DDS O.C. PREM PLS PLN W/OP DDS O.C. PREM PLS PLN W/HI DDS ENDRSD ORANGE CO. B ONLY SV 20-40/50% 07 AB 110 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ERS ES1 ES2 ES3 ES4 ES5 ES6 ES7 ES8 ES9 ESA ESB ESC ESD ESE ESF ESG ESH ESI ESJ ESK ESL ESM ESN ESO ESP ESQ ESR ESS EST ESU ESV ESW ESX ESY ESZ ET1 ET3 ET5 ET9 ETB ETC ETH ETJ ETL ETN ETU ETZ EU3 EU5 Plan / Benefit Description SH RIVERSIDE - ENDORSED SR PLAN RX SO. CAL SR PLUS RX - SO CALIF SR PLAN RX NO CAL SR PLUS NO CAL SR PLAN PREMIER-NO CAL SR PLAN RX ELDORADO,SACTO. SR PLAN RX-SOLANO,SONOMA SR PLUS RX-SOLANO,SONOMA SR PRMIER RX-SOLANO,SONOMA ENDRSD RETIREE SO.CA STD ENDRSD RETRE SO.-PART B ON ENDRSD RETRE S.CRUZ ENDRSD RETIREE SAC/ELDORD SH SAN BERNARDINO - ENDORS SH SAN FRANCISCO - ENDORSE SH SANTA BARBARA - ENDORSE SH STANISLAUS - ENDORSED ENDR STANISLAUS B ONLY SH SAN JOAQUIN - ENDORSED SH SANTA CRUZ - ENDORSED ENDRSD RETRE -SLO/SB ENDR RET SAN MATEO B-ONLY ENDORSED STANISLAUS ENDRSD RETRE SOL/SONM PRTB SH SLO - ENDORSED SH SANTA CLARA - ENDORSED SH SACRAMENTO - ENDORSED ENDRSD RETRE SOLA/SONOM ENDRSD RETREE STANISLAUS ENDRSD RET.STNISLAS PRT B SH SONOMA - ENDORSED SH SOLANO - ENDORSED SH SAN DIEGO - ENDORSED SH SAN MATEO - ENDORSED ENDRSD RETIREE S.CRUZ PRTB EAP TELEPHONIC MCC VALU S DEGO LO-PL SH07 MCC VALU S DEGO HI-PL SH07 MCC VALU S DEGO PLUS SH07 ENDRD RT CONT COSTA B ONLY SP 10/100% EDISON 06 MCC VALU S DEGO HIGH SH07 SP 10/100% EDISON 06 AB MCC VALU S DEGO LOW SH07 MC COMP VALUE S DEGO SH07 SH TULARE - ENDORSED SP 10/100% EDISON 06 CB MCC PRE S DIEGO LO-PL SH07 MCC PRE S DIEGO HI-PL SH07 111 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit EU9 EUH EUL EUN EVB EVT EWD EWE EWH EXC EXD EXE EXJ EXP EXZ EZ1 EZC F01 F02 F03 F04 F05 F06 F07 F08 F09 F0C F0J F0N F10 F11 F12 F13 F14 F15 F16 F17 F18 F19 F1C F1D F1E F1F F1G F1J F1K F1N F1P F1Q F1R Plan / Benefit Description MCC PRE S DIEGO PLUS SH07 MCC PRE S DIEGO HIGH SH07 MCC PRE S DIEGO LOW SH07 MC COMP PRE SAN DIEGO SH07 ENDRD RET-VENTURA B ONLY SH VENTURA - ENDORSED SAN DIEGO CLASS III DDS SAN DIEGO CLASS III PPO SAN DIEGO CLASS III HI DDS SV 20/100A EXPERIAN 07 SV 20/100A EXPERIAN 07 CB SV 20/100A EXPERIAN 07 AB SV $20/$100A EXPERIAN AB SV $20/$100A EXPERIAN SV $20/$100A EXPERIAN CB PREFERRED-$0 ER PLAN COBRA 10/100% EDISON-F AARP GR08 LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO FEDERAL EMPLOYEES 2000 SV 10-15/250A FIDELITY AB SELF FND OOA PREMIUM ALLOC LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO STANDARD 10 PLAN II ELITE 10 FED CBR DISABLED ELITE 10 FED CBR EXTENDED ELITE 10 CAL CBR EXTENDED ELITE 10 CAL CBR DISABLED SIGPOS 30 PLUS AB POS 300 PLUS FRESNO STANDARD PLAN STANDARD 10 PLAN (POS) INDIVIDUAL POS-$250 DEDUCT ELITE 10 CAL COBRA 112 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit F1S F1U F1W F1Y F1Z F20 F21 F22 F23 F24 F25 F26 F27 F28 F29 F2A F2C F2D F2E F2F F2G F2J F2K F2P F2Q F2R F2S F2W F2Y F2Z F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F3A F3B F3C F3D F3E F3F F3G F3J F3K F3P Plan / Benefit Description ELITE 10 POS 300 PLUS USERRA ELITE 10 COBRA STAND 10 (POS) COBRA STANDARD 10 PLAN COBRA II LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO SV 15-30/250A FRMRS 06 CB MFP STANDARD 10 PLAN II PREMIER 10 FED CBR DISABLE PREMIER 10 FED CBR EXTEND PREMIER 10 CAL CBR EXTEND PREMIER 10 CAL CBR DISABLE MFP STANDARD 10 PLAN II AB POS 300 PLUS COBRA MFP STD 10 - POS INDIVIDUAL POS $500 DEDUCT PREMIER 10 PLAN CAL CBRA PREMIER 10 PLAN PREMIER 10 PLAN CBRA MFP STD 10 - POS (COBRA) MFP STANDARD 10 PLAN CBRII LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO ELITE POS 300 ELITE POS 300 COBRA STANDARD 10/25 PLAN TEST ELITE POS 300 FED CBR DISA ELITE POS 300 FED CBR EXTE ELITE POS 300 CAL CBR EXTE ELITE POS 300 CAL CBR DISA CITIGROUP $15/$25/$500A AB POS 300 PLUS CAL CBRA BENEFIT ALLIANCE - POS 113 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit F3Q F3R F3S F3Y F3Z F41 F42 F43 F44 F45 F46 F47 F48 F49 F4A F4B F4C F4D F4E F4F F4G F4J F4K F4P F4Q F4R F4S F4Y F4Z F50 F51 F52 F53 F54 F55 F56 F57 F58 F59 F5A F5B F5C F5D F5E F5F F5G F5J F5K F5Q F5R Plan / Benefit Description INDIVIDUAL POS $1000 DED. ELITE POS 300 CAL COBRA SUTTER HEALTH PLAN BENEFIT ALLIANCE POS COBRA STANDARD 10/25 PLAN-COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO PREMIER POS 300 PLAN PREMIER POS 300 PLAN CBRA BENEFIT ALLIANCE PLAN B PREM POS 300 FED CBR DISAB PREM POS 300 FED CBR EXTEN PREM POS 300 CAL CBR EXTEN PREM POS 300 CAL CBR DISAB CALIFORNIA FAMILY HLTH AB POS 300+ FED CBR DIS SUTTER HEALTH $10 POS IND POS $10/$250 (COP) PREMIER POS 300 PLAN CCBRA SUTTER HEALTH PLAN COBRA SUTTER HEALTH $10 POS CBRA BENEFIT ALLIANCE B COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO ELITE POS 500 ELITE POS 500 COBRA PBGH 10 ELITE POS 500 FED CBR DISA ELITE POS 500 FED CBR EXT ELITE POS 500 CAL CBR EXTE ELITE POS 500 CAL CBR DISA SV VERIZON $15/100% AB POS 300+ FED CBR EXTE IND POS $10/$500 (COP) ELITE POS 500 CAL COBRA 114 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit F5Z F60 F62 F63 F64 F65 F66 F67 F6A F6B F6C F6D F6E F6F F6G F6J F6K F6Q F6R F6Z F72 F73 F74 F75 F76 F77 F7A F7B F7C F7D F7E F7F F7G F7J F7K F7Q F7R F7S F7Z F82 F83 F84 F85 F86 F87 F8C F8J F8P F8Q F8R Plan / Benefit Description PBGH 10 COBRA LIMITED FEE SCHEDULE PPO KEC 3 FRESNO CG GR07 KEC 3 FRESNO EP CG GR07 KEC 3 FRESNO E-P CG GR07 KEC 3 FRESNO PP CG GR07 KEC 3 FRESNO P-P CG GR07 KEC 3 FRESNO PL CG GR07 PREMIER POS 500 PLAN PREMIER POS 500 PLAN CBRA PBGH 10/50 PREM POS 500 FED CBR DISAB PREM POS 500 FED CBR EXTEN PREM POS 500 CAL CBR EXTEN PREM POS 500 CAL CBR DISAB $10-$15/100% AB POS 300+ CAL CBR DISA IND POS $10/$1000 (COP) PREMIER POS 500 PLAN CCBRA PBGH 10/50 COBRA KEC 3 FRESNO CGII GR07 KEC 3 FRESNO EP CGII GR07 KEC 3 FRESNO E-P CGII GR07 KEC 3 FRESNO PP CGII GR07 KEC 3 FRESNO P-P CGII GR07 KEC 3 FRESNO PL CGII GR07 PREMIER POS 300 PLUS PREMIER POS 300 PLUS COBRA MODIFIED STANDARD 10-RETA PREM POS 300+ FED CBR DIS PREM POS 300+ FED CBR EXTE PREM POS 300+ CAL CBR DISA PREM POS 300+ CAL CBR EXTN SP 10/100% FRFLD 05 AB POS 300+ CAL CBR EXTN G/I INDIVIDUAL POS-250 DED PREM POS 300 PLUS CAL CBRA AB1401 SUTTER HEALTH PLAN MODIFIED 10 STD RETA COBRA KEC 3 FRESNO CGEH GR07 KEC 3 FRESNO EP CGEH GR07 KEC 3 FRESNO E-P CGEH GR07 KEC 3 FRESNO PP CGEH GR07 KEC 3 FRESNO P-P CGEH GR07 KEC 3 FRESNO PL CGEH GR07 CHW 10 HMO SV 25/250A FRFLD 05 AB CHW POS INDIVID POS $500 7/00 SV 25/250A FRFLD 05 CB 115 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit F8Y F8Z F9A F9J F9P F9Q F9Y F9Z FA2 FA3 FAA FAB FAC FAD FAE FAF FAJ FAK FAQ FAX FAZ FB1 FB2 FB3 FB4 FB6 FB8 FBA FBC FBJ FBK FBQ FBZ FC1 FC2 FC3 FC4 FC6 FC7 FC8 FC9 FCA FCB FCC FCD FCE FCF FCG FCH FCI Plan / Benefit Description CHW POS COBRA CHW 10 HMO COBRA CUSTOM 10 BOEING HMO CUSTOM 10 BOEING HMO AB NON STD POS 100/80/70 G/I INDIVID POS $500 7/00 NON STD POS 100/80/70 CBRA CUSTOM 10 BOEING HMO COBRA AT&T ADVANTAGE $10/$15 AT&T ADVANTAGE $10/$15 CBR SV 15-30/250A FRMRS 06 SV $10/100% AIWU HMO $10/250 SV $10/100% CB SV $10/$20/$100D SV $10/$20/$100D CB SV $10/100% AB SV $10/$20/$100D AB INDIVID POS $1000 7/00 SV 15-30/250A FRMRS 06 AB AIWU HMO $10/250 CBRA BOEING IAM HMO $10 BOEING IAM HMO $10 COBRA JOINT BENEFIT 20/40/400 JOINT BENEFIT 20/40/400 CB JOINT BEN 20/40/400A JOINT BEN 20/40/400A COBRA $5G/$10B BAXTER PLAN PEPSICO AB KEC 3 FRESNO EP GR07 G/I INDIVID POS $1000 7/00 BAXTER PLAN COBRA SCHS HMO $10/$250 SCHS HMO $10/$250 COBRA CALIFORNIA FAMILY HLTH CALIFORNIA FAMILY HLTH CBR $10-$15/100% $10-$15/100% COBRA RESERVED FOR RX PPO RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX DUMMY $35/$150A RESERVED FOR PPO RX RESERVED FOR PPO RX GM HOURLY HMO 2002 OON CHIRO CNTY OF FRESNO RESERVED FOR PPO RX 116 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit FCJ FCL FCM FCN FCP FCQ FCY FCZ FD2 FD3 FD5 FDC FDD FDF FDJ FDQ FDX FDZ FE1 FE2 FE3 FE4 FE5 FE6 FE7 FEB FEC FED FEE FEF FEJ FEP FEQ FEW FEX FEZ FF1 FF2 FF3 FF4 FF5 FF6 FF7 FF8 FF9 FFA FFB FFC FFF FFI Plan / Benefit Description RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX $35/$150A COBRA INDIVIDUAL 1000 POS GM HOURLY HMO 2002 COBRA DUMMY SDSU $10/$100A SDSU $10/$100A COBRA SV 10-30/100D FEDS 05 HMO 10 PLAN-CUSTOM SV 35/240A FDLTY NIS 06 SV 35/240A FDLTY NIS 06 CB SDSU $10/$100A AB INDIVIDUAL 1000 POS HIPPA SV 35/240A FDLTY NIS 06 AB HMO 10 PLAN-CUSTOM COBRA UNIVERSAL PLAN (STAND 3) FEDERAL EMPLOYEES PLAN FEDERAL EMPLOYEE PLAN 1992 FEDERAL EXPRESS $25/$100 FEDERAL EXPRESS 25/100 CBR SV FED EX $25/$100A SV FED EX $25/$100A CB SV 10-30/100D FEDS 08 PBGH 10 FEHB SPECIAL ALLOCATION CD SV 25/100A FEDEXPRS 06 SV 25/100A FEDEXPRS 06 CB SV FED EX $25/$100A AB EDISON INT'L POS 10-ACTIVE EDISON INT'L POS PREFERRED FRESNO CLASSIC I W/EPO DDS SV 25/100A FEDEXPRS 06 AB PBGH 10 (COBRA) SAN BERNARDINO USD HMO SAN BERNARDINO USD COBRA HMO 10 PLAN HMO 10 PLAN CBRA HMO 10 PLAN CAL CBRA HMO 10 FED CBR DISABLED HMO 10 FED CBR EXTENDED HMO 10 CAL CBR EXTENDED HMO 10 CAL CBR DISABLED SAN BERNARDINO USD POS SAN BERNARDINO USD COBRA WELLS FARGO BANK ADMINISTRATIVE RETENTION ADMIN RETENT IN-NETWORK 117 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit FFJ FFO FFP FFQ FFR FFU FFW FFY FFZ FG2 FG3 FG5 FG6 FG7 FGA FGB FGC FGG FGJ FGP FGQ FGY FGZ FH1 FH2 FH4 FH5 FH6 FHA FHB FHC FHJ FHL FHU FHX FHZ FIC FID FIJ FIN FIP FIY FIZ FJ1 FJ2 FJC FJJ FJK FJN FJP Plan / Benefit Description HMO 10 AB ADMIN RETENT OUT-NETWORK STD 10 POS-PEPSI/FRITO INDIVIDUAL 500 POS SP 10/100% FRFLD 05 CB HMO 10 PLAN USERRA INACTIVE STD 10 POS PEP/FRITO-COBRA WELLS FARGO BANK (COBRA) CITIGROUP $15/$25/$500A CITIGROUP $15/$25/$500A CB SV 15-25/500A CITIGROUP SV 15-25/500A CITIGROUP CB $7/$10 FORMULARY/GENERIC SV 25/250A FRFLD 07 SV 25/250A FRFLD 07 CB PBGH 10 SV 25/250A FRFLD 07 AB SV 15-25/500A CITIGROUP AB $15 PEPSI/FRITO LAY INDIVIDUAL 500 POS HIPPA $15 PEPSI/FRITO LAY COBRA PBGH 10 (COBRA) $10/100%HMO MFP2000 SERIES $10/100%HMO MFP2000 SER CB SV 15/100% CAFHC 05 SV 15/100% CAFHC 05 CB SV 10-30/100D FEDS 06 SV 15/100% CFHC 06 IBM-F2191 RETIREE GOLD $10 HMO 2000 SER $10 HMO 2000 AB SV 15/100% CFHC 06 CB $10 2000 SER USERRA SV 15/100% CFHC 06 AB $10 HMO 2000 CBRA DUMMY PLAN-NOT IN USE FEDS DENTAL INDEMNITY 2001 SV 15-30/250A FARMERS AB SV 15-30/250A FARMERS STANDARD 10/POS ITT STANDARD 10/POS ITT COBRA DUMMY PLAN-NOT IN USE CUSTOM POS 100%/80%/70% CSTM POS100%/80%/70% CBRA CUSTOM HMO $10/$250 NON STD POS 100/80/70 AB KEC 3 FRESNO EP-PL GR07 FEDS 2003 SJHS-STD 10 MFP POS 118 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit FJY FJZ FK1 FK2 FK3 FK4 FK5 FK6 FK7 FKA FKC FKJ FKN FKP FKU FKY FKZ FL1 FL2 FL3 FLC FLJ FLP FLY FLZ FM2 FM3 FM4 FM5 FM6 FM7 FMA FMB FMC FMD FME FMF FMG FMJ FMK FMY FMZ FN1 FN2 FN3 FN4 FN8 FN9 FNA FNB Plan / Benefit Description SJHS-STD 10 MFP POS COBRA CUSTOM HMO $10/$250 COBRA HMO 10 PLAN HMO 10 PLAN CBRA HMO 10 PLAN CAL CBRA HMO 10 FED CBR DISABLE HMO 10 FED CBR EXTEND HMO 10 CAL CBR EXTEND HMO 10 CAL CBR DISABLE SV 10-15/250A FIDNTL 06 KEENAN COMP 3 FRESNO GR07 SV 10-15/250A FIDNTL 06 AB FEDS 2004 $10 POS MFP SJHS N CAL EXC HMO 10 PLAN USERRA $10 POS MFP SJHS EX COBRA SV 10-15/250A FIDNTL 06 CB $10/100% NON STANDARD $10/100% NON STANDARD CBRA LOCKHEED $10 DUMMY PLAN-NOT IN USE SP 10/100% OPT 69 AB LIBERTY MUTUAL POS LIBERTY MUTUAL POS COBRA DUMMY PLAN-NOT IN USE TOYOTA MOTOR $10/100% TOYOTA MOTOR $10/100% CBRA MARSH & MCLENNAN 20/100 $5G/$10B $10/$20MAIL CL RX MARSH & MCLENNAN 20/100 CB RETIREE RX $7/$10 UNLIM. FRESNO/MADERA BASIC PLAN FRESNO/MADERA PRT B ONLY 10/50 PLAN SV 25/10% FEDEXPRS 07 SV 25/10% FEDEXPRS 07 CB SV 25/10% FEDEXPRS 07 AB GM SLRY HMO 2002 MARSH & MCLENNAN 20/100 AB KEC 3 FRESNO PP GR07 GM SLRY HMO 2002 COBRA 10/50 PLAN HOTEL NIKKO 100/80/70 HOTEL NIKKO 100/80/70 CBRA POS $10 - MFP POS $10 - MFP COBRA FIDELITY $10/$250 FIDELITY $10/$250 COBRA SV 10-15/250A FIDELITY SV 10-15/250A FIDELITY CB 119 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit FNC FNJ FNK FNL FNP FNS FNZ FOA FP2 FP3 FP4 FP5 FP6 FP7 FP8 FP9 FPA FPB FPC FPD FPE FPF FPJ FPK FPL FPM FPP FPR FPS FPV FPW FPX FPY FPZ FQ3 FQ4 FQC FQJ FQK FQP FQY FQZ FR1 FR6 FR7 FR8 FRA FRB FRC FRH Plan / Benefit Description MARTIN MARIETTA ($20 ER) FIDELITY $10/$250 AB SV 25/240A FIDELITY 07 SV 25/240A FIDELITY 07 CB SV 25/240A FIDELITY 07 AB SV 15-30/250A FARMERS CB MARTIN MARIETTA ($20)COBRA FREEDOM PRVDR OPEN ACCESS POWAY USD POWAY USD COBRA PHARMINGEN PHARMINGEN COBRA $30/100% $30/100% COBRA TRAVELERS PROP 15-25/250A TRAVELERS 15-25/250A COBRA FPA CLAIMS PROCESS-NO BENE $10/100% STANDARD 10 PLAN PEPSICO PEPSICO $10/100% COBRA SP 10/100% FRFLD 07 SP 10/100% AB SP 10/100% SP 10/100% OPT 69 SP 10/100% 06 STAND 10 CHOICE/POLY COOK PREMIUM REVERSAL SP 10/100% 06 CB SP 10/100% CB SP 10/100% OPT 69 CB SP 10/100% 06 AB STAND 10 CHCE/PLY CK COBRA STANDARD 10 PLAN PEP COBRA CUSTOM POS 100/80/60 CUSTOM POS 10/80/60 COBRA 100%/80%/60% POS MFP POS $10 - MFP AB KEC 3 FRESNO PP-PL GR07 $10/250 POS MFP SJHS-NC $10/250 POS MFP SJHS COBRA 100%/80%/60% POS MFP COBRA FEDERAL RETIREES PLAN FAIRFIELD RES $25/$250A FAIRFIELD RES $25/$250A CB SV 25/250A FRFLD 05 RISK CHARGE - AGGREGATE MCD-A1325 RETIREE GOLD ROCKWELL-SALARY SP 10/100% FRFLD 05 120 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit FRI FRJ FRK FRM FRO FRP FRS FRY FRZ FS1 FS2 FS3 FS4 FS5 FS6 FS7 FS8 FSA FSC FSD FSE FSF FSG FSJ FSL FSM FSP FSY FSZ FTC FTD FTJ FTL FTY FTZ FU6 FU7 FU9 FUE FUF FUJ FUN FUP FUT FUZ FV2 FV3 FV4 FV5 FV6 Plan / Benefit Description IN-NETWORK SPC/AGG RISK FARMERS INS AB KEC 3 FRESNO PLUS GR07 FARMERS INS OUT-NETWORK SPC/AGG RISK $10 POS AZUSA USD RISK CHARGE - SPECIFIC $10 POS AZUSA USD COBRA ROCKWELL-SALARY COBRA SH FRESNO STD MED PLAN SH FRESNO STD MED W/ HI DE SH FRESNO PART B STD MED SH FRESNO PART B W/ HI DEN SH FRESNO PLUS PLAN MED SH FRESNO PLUS W/ HI DEN SH FRESNO PART B PLUS MED SH FRESNO B PLUS W/ HI DEN SO.CAL.SENIOR PLAN BASIC 10/50 CUSTOM SV $10/100% SV $10/100% CB SV 10/100% 06 SV 10/100% 06 CB SV $10/100% AB SILVER SNEAKER SH/GR-WL07 FRESNO CLASSIC I SJHS-STD 10 MFP POS SJHS-STD 10 MFP POS COBRA 10/50 CUSTOM - COBRA NORDSTROM HMO PLAN NORDSTROM HMO 2001 SV 15/100% CAFHC 05 AB SILVER SNEAKER SH/GR-WL08 NORDSTROM HMO 2001 COBRA NORDSTROM HMO PLAN CBRA MCC 1 FRESNO PP-PL SH07 MCC 1 FRESNO EP-PL SH07 MCC 1 FRESNO PLUS SH07 MCC 1 FRESNO EP SH07 SP 10/100% FRFLD 07 CB SV 10/100% 06 AB MC COMP 1 FRESNO SH07 MCC 1 FRESNO PP SH07 STANFORD CSTM 10/50 PLAN STANFORD CSTM CBRA 10/50 VERIZON WIRELESS 10/100% VERIZON WIRELESS 10/100%CB SV VERIZON $15/100% SV VERIZON $15/100% CB SV 15/100% VERIZON 06 121 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit FV7 FVA FVF FVI FVJ FVQ FVU FVV FVW FVX FVY FVZ FW1 FWC FWP FWZ FXB FXC FXE FXF FXI FXJ FXQ FXU FXV FXW FXX FXY FXZ FY6 FY7 FY9 FYB FYC FYE FYJ FYN FYP FYZ FZ1 FZB FZD FZJ FZL FZM G0C G0D G1C G1J G1K Plan / Benefit Description SV 15/100% VERIZON 06 CB $10/100 NORTHROP GRUMMAN SP 10/100% FRFLD 07 AB ARP MCC 1 FRSNO EP-PL SH08 VERIZON WIRELESS 10/100%AB ARP MCC 1 FRSNO PP-PL SH08 ARP MCC 1 FRSNO PP SH08 ARP MCC 1 FRSNO PLUS SH08 ARP MCC 1 FRSNO SH08 SV 15/100% VERIZON 06 AB ARP MCC 1 FRSNO EP SH08 $10/100 NORTHROP GRUM CBR FOOTWARE FOR DISFIGUREMENT 10/50-CUSTOM PLAN FRESNO CLASSIC I W/ODP DDS 10/50 CUSTOM PLAN - COBRA SP 10/100% FREMONT 07 $10 HMO AZUSA USD SV 15/100A FOX 06 SV 15/100A FOX 06 CB ARP MCC 3 FRSNO EP-PL SH08 $10 HMO AZUSA USD AB ARP MCC 3 FRSNO PP-PL SH08 ARP MCC 3 FRSNO PP SH08 ARP MCC 3 FRSNO PLUS SH08 ARP MCC 3 FRSNO SH08 SV 15/100A FOX 06 AB ARP MCC 3 FRSNO EP SH08 $10 HMO AZUSA USD COBRA MCC 3 FRESNO PP-PL SH07 MCC 3 FRESNO EP-PL SH07 MCC 3 FRESNO PLUS SH07 SP 10/100% FREMONT 07 CB 10/50 NEW YORK COALITION MCC 3 FRESNO EP SH07 STAND 10 (POS) AB MC COMP 3 FRESNO SH07 MCC 3 FRESNO PP SH07 10/50 N.Y.COALITION (COBRA UNIVERSAL PLAN (FEDS)COBRA SP 10/100% FREMONT 07 AB PEPSICO COBRA STANDARD 10 PLAN II AB LOCKHEED $10 - COBRA FARMERS INS COBRA FEDERAL EMPLOYEES 2001 FEDS DOD EMPLOYEES 2001 STANDARD 15 PLAN $15/80-60 SG AB $15/80-60 SG 122 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit G1P G1Y G1Z G22 G23 G24 G25 G26 G27 G28 G29 G2C G2J G2K G2P G2Y G2Z G32 G33 G34 G35 G36 G37 G38 G39 G3J G3K G42 G43 G44 G45 G46 G47 G48 G49 G4J G4K G5J G5K G5M G6J G6K G6M G6N G6R G6X G6Y G6Z G7J G7K Plan / Benefit Description STANDARD 15 PLAN POS STANDARD 15 PLAN POS CB STANDARD 15 PLAN COBRA KEC ORANGE CG GR07 KEC ORANGE LO CG GR07 KEC ORANGE LO-PL CG GR07 KEC ORANGE HI CG GR07 KEC ORANGE HI-PL CG GR07 KEC ORANGE PL CG GR07 KEC ORANGE DLXE CG GR07 KEC ORANGE PL-DX CG GR07 $20 HMO 2000 SER $20 HMO 2000 SER AB $15/80-60 SG COBRA NONSTD 15 POS100/80/60 NONSTD 15 POS100/80/60 CB $20 HMO 2000 SER CBRA KEC ORANDE CGII GR07 KEC ORANGE LO CGII GR07 KEC ORANGE LO-PL CGII GR07 KEC ORANGE HI CGII GR07 KEC ORANGE HI-PL CGII GR07 KEC ORANGE PL CGII GR07 KEC ORANGE DLXE CGII GR07 KEC ORANGE PL-DX CGII GR07 SV CAPITAL 25/30/500A AB $15/80-60 SG CAL COBRA KEC ORANGE CGEH GR07 KEC ORANGE LO CGEH GR07 KEC ORANGE LO-PL CGEH GR07 KEC ORANGE HI CGEH GR07 KEC ORANGE HI-PL CGEH GR07 KEC ORANGE PL CGEH GR07 KEC ORANGE DLXE CGEH GR07 KEC ORANGE PL-DX CGEH GR07 20/250A 100 O/P AB $15/80-60 SG FED CBR DIS GROSSMONT UHSD $10/100% AB $15/80-60 SG FED CBR EXT GR 20/100% GM SAL $20/$250A/$50 AB $15/80-60 SG CAL CBR EXT SV 20-30/100% GM 06 SV 10/100% GM 06 SV 10/100% GM 06 CB SV 20-30/100% GM 06 AB SV 10/100% GM 06 AB SV 20-30/100% GM 06 CB $20/$100 AB $15/80-60 SG CAL CBR DIS 123 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit G7M G8K G9J GA2 GA3 GA3 GA4 GA5 GA7 GA8 GA9 GAA GAB GAC GAF GAJ GAN GAX GAZ GB2 GB3 GB4 GB5 GB6 GB7 GB8 GBA GBC GBD GBE GBF GBG GBH GBJ GBK GBM GBN GBY GC1 GC2 GC3 GC5 GC6 GC8 GCA GCB GCD GCE GCJ GCL Plan / Benefit Description SH 10/100% GM-H GR06 $15/80-60 SG USERRA SV10/100 GNRL MTRS-HRLY AB $20/$300 HMO $20/$300 COBRA EAP PLAN A GATE $20/$300 COBRA EAP PLAN A GATE $20/$100 EAP PLAN A GATE $20/$100 COBRA SV $15/$30/80% SV $15/$30/80% CB SV 15/100% SC GLAZ 06 SV 15/100% SC GLAZ 06 CB SV $15/$30/80% AB SV 20/250A GANNETT SV 15/100% SC GLAZ 06 AB SV 20/250A GANNETT CB 20/250A 100 O/P EAP PLAN B GATE 20/250A 100 O/P COBRA EAP PLAN B GATE $20/$250A/$50 $20/$250A/$50 COBRA EAP PLAN B GATE POS 100/80/70 $20OV $15/$100A $15/$100A COBRA PBGH $20/100%/$50ER PBGH $20/100%/$50ER COBRA $25/$250A $25/$250A COBRA $20/$250A 3000 OOP $20/$250A 3000 OOP COBRA $25/$250A $25/$250A COBRA POS 100/80/70 $20OV COBRA CAPITAL GROUP CAPITAL GROUP COBRA EAP PLAN C GATE EAP PLAN C GATE SV 25/250A GCBT 06 EAP PLAN C GATE KEENAN COMP ORANGE GR07 GOLD CST BENEFIT TRUST ORANGE CLASSIC I W/OP DDS ORANGE CLASSIC I W/EPO DDS STANDARD 15 PLAN AB SV 25/250A GCBT 06 CB 124 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit GCR GCS GCT GCY GCZ GDA GDC GDD GDE GDF GDJ GDX GDZ GE2 GE3 GE4 GE5 GE6 GE7 GEA GEB GEC GEE GEF GEG GEJ GEK GEL GEM GEN GEO GEP GES GET GEU GEV GEW GEX GEZ GF2 GF3 GFA GFE GFF GFJ GGC GGD GGF GGJ GGX Plan / Benefit Description SV 25/250A GCBT 06 AB ORANGE CLASSIC I SV 25/25OA GCBT 05 SV 25/250A GCBT 05 CB GOLD CST BENEFIT TRUST CBR SP 10/100% GULFSTRM 06 SV 10/100% GOODRICH-SAL SV 10/100% GOODRICH-SAL CB SV 20/80% GOODRICH SAL SV 20/80% GOODRICH SAL CB $15/$100A AB SP 10/100% GULFSTRM 06 AB SP 10/100% GULFSTRM 06 CB SV 15-30/250A GEVT1 06 AB SV 15-30/250A GEVT2 06 AB SV 15-30/250A GEVT3 06 AB SV 15-30/250A GEVT4 06 AB SV 15-30/250A GEVT5 06 AB SV 15-30/250A GEVT6 06 AB KEC ORANGE LOW GR07 SV 15-30/250A GEVT1 06 SV 15-30/250A GEVT2 06 SP 15/100% GULFSTRM 08 SV 15-30/250A GEVT3 06 SV 15-30/250A GEVT4 06 PBGH $20/100%/$50ER AB SV 15-30/250A GEVT5 06 SV 15-30/250A GEVT6 06 SV20/100 GNRL MTRS-SLRY SV20/100 GNRL MTRS-SLRY CB SV10/100 GNRL MTRS-HRLY SV10/100 GNRL MTRS-HRLY CB ORANGE CLASSIC ENHANCED SV 15-30/250A GEVT1 06 CB SV 15-30/250A GEVT2 06 CB SV 15-30/250A GEVT3 06 CB SV 15-30/250A GEVT4 06 CB SV 15-30/250A GEVT5 06 CB SV 15-30/250A GEVT6 06 CB FORD MOTOR CREDIT CORP FORD MOTOR CREDIT CORP CBR KEC ORANGE LO-PL GR07 SP 15/100% GULFSTRM 08 CB SP 10/100% GROSSMONT 07 FORD MOTOR CREDIT CORP AB SP 10/100% GULFSTRM 07 SV 25/100% GGUSD 06 SV 20-40/80% G&S 08 $25/$250A AB SP 10/100% GIGANTE 06 125 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit GGY GGZ GH2 GH3 GHA GHD GHF GHJ GI3 GI5 GIF GIH GIL GIO GIP GIV GIW GIX GIY GJA GJF GJG GJJ GKA GKC GKJ GKZ GL3 GL5 GLA GLD GLE GLF GLH GLJ GLL GLO GLV GLW GLX GLZ GM1 GM2 GM3 GM4 GM5 GM6 GM7 GM8 GM9 Plan / Benefit Description SP 10/100% GIGANTE 06 CB SP 10/100% GIGANTE 06 AB $20/$200 $20/$200 COBRA KEC ORANGE HIGH GR07 ORANGE CLSC ENHNCD W/HIDDS SP 10/100% GROSSMONT 07 CB $20/$200 AB ARP MCC 2 OR LO-PL SH08 ARP MCC 2 OR HI-PL SH08 GIFT BENEFIT RIDER ARP MCC 2 OR HI SH08 ARP MCC 2 OR LO SH08 ARP MCC 2 OR PL-DLX SH08 STANDARD 15/POS ITT ARP MCC 2 OR PLUS SH08 ARP MCC 2 OR SH08 ARP MCC 2 OR DLX SH08 STANDARD 15/POS ITT COBRA KEC ORANGE HI-PL GR07 SV 20-40/80% G&S 08 CB SP 10/100% GEN INST 07 $20/$250A 3000 OOP AB SV 10/80% GRC-H 06 SP 10/100% GULFSTRM 07 CB SV 10/80% GRC-H 06 AB SV 10/80% GRC-H 06 CB ARP MCC PRE OR LO-PL SH08 ARP MCC PRE OR HI-PL SH08 SV 5/100% GRC-H 06 ORANGE CLSC ENHNCD W/OPDDS SP 15/100% GULFSTRM 08 AB SV 20-40/80% G&S 08 AB ARP MCC PRE OR HI SH08 SV 5/100% GRC-H 06 AB ARP MCC PRE OR LO SH08 ARP MCC PRE OR PL-DLX SH08 ARP MCC PRE OR PLUS SH08 ARP MCC PRE OR SH08 ARP MCC PRE OR DLX SH08 SV 5/100% GRC-H 06 CB GENERAL MOTORS SALARIED GENERAL MOTORS SALARIED CB GEN MOTORS SAL CUST $3 GEN MTRS GRP RET SLRY GENERAL MOTORS HOURLY GENERAL MOTORS HOURLY CBRA GEN MTRS GRP RET SLRY SV $20/100% SV $20/100% CB 126 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit GMC GMH GMJ GMK GMR GMS GMT GMZ GN1 GN2 GNA GNG GNJ GO3 GO5 GOH GOJ GOL GOO GOV GOW GOX GP1 GPA GPB GPD GPE GPH GPJ GPP GPS GQ3 GQ5 GQA GQH GQJ GQL GQO GQV GQW GQX GR1 GR5 GRA GRB GRE GS1 GS5 GS6 GSA Plan / Benefit Description GENERAL MOTORS-CUSTOM RET. GENERAL MTRS GRP RET HRLY SV $20/100% AB 20-30/100% GEN MOTRS GR06 $7G/$15B/$15NF GENERAL MTRS GRP RET SLRY SH RETIREE GM CUSTOM $3 SH RETIREE CUSTOM GM $0 NORTHROP GRUMMAN 10/20 NORTHROP GRUMMAN 10/20 CBR KEC ORANGE PLUS GR07 SP 10/100% GEN INST 07 CB SV 20/250A GANNETT AB ARP MCC VA OR LO-PL SH08 ARP MCC VA OR HI-PL SH08 ARP MCC VA OR HI SH08 SV20/100 GNRL MTRS-SLRY AB ARP MCC VA OR LO SH08 ARP MCC VA OR PL-DLX SH08 ARP MCC VA OR PLUS SH08 ARP MCC VA OR SH08 ARP MCC VA OR DLX SH08 SUTTER 100%/90%/70% COBRA SUTTER 100%/90%/70% PITNEY BOWES 20/30/250 ORANGE PREMIER W/OPT DDS ORANGE PREMIER W/EPO DDS ORANGE PREMIER W/HI OP DDS SV 20/80% GOODRICH SAL AB PITNEY BOWES 20/30/250 COB ORANGE PREMIER ARP MCC OR LO-PL SH08 ARP MCC OR HI-PL SH08 KEC ORANGE DELUXE GR07 ARP MCC OR HI SH08 SV 10/100% GOODRICH-SAL AB ARP MCC OR LO SH08 ARP MCC OR PL-DLX SH08 ARP MCC OR PLUS SH08 ARP MCC 1 OR SH08 ARP MCC OR DLX SH08 SUTTER CUSTOM 5 PLAN CBRA AB1401 SUTTER CUSTOM 5 PLN SUTTER CUSTOM 5 PLAN SV 25/100% GGUSD 06 CB SV 25/100% GGUSD 06 AB SUTTER CUSTOM 15 PLAN CBRA GROSSMONT UHSD $10/100% GROSSMONT UHSD $10/100% CB SUTTER CUSTOM 15 PLAN 127 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit GSE GSF GSH GSJ GSM GT1 GT3 GT5 GT9 GTA GTD GTF GTG GTH GTJ GTL GTN GTO GUA GUH GUJ GUX GUY GUZ GV2 GV3 GV4 GV5 GV6 GV7 GVA GVB GVC GVD GVE GVF GVG GVH GVJ GVK GVL GVS GVT GVU GVV GVW GVX GVY GVZ GW2 Plan / Benefit Description ORANGE MEDICAL W/EPO DDS SPECIALIZED FTWEAR 20% 06 ORANGE MEDICAL W/HI OP DDS SUTTER CUSTOM 15 PLAN AB ORANGE MEDICAL EAP TELEPHONIC GATE MCC ESS ORNGE LO-PL SH07 MCC ESS ORNGE HI-PL SH07 MCC ESS ORNGE PLUS SH07 KEC ORANGE PL-DX GR07 MCC ESS ORNGE DELUXE SH07 SP 10/100% GROSSMONT 07 AB SP 10/100% GEN INST 07 AB MCC ESS ORNGE HIGH SH07 SV 25/250A GCBT 05 AB MCC ESS ORNGE LOW SH07 MC COMP ESS ORNGE SH07 MCC ESS ORNGE PL-DLXE SH07 SV 10/500D 05 SP 10/100% GUHSD 06 SV 10/500D 05 AB SP 10/100% GUHSD 06 AB SP 10/100% GUHSD 06 CB SV 10/500D 05 CB SV 20-40/500D GEVT1 06 AB SV 20-40/500D GEVT2 06 AB SV 20-40/500D GEVT3 06 AB SV 20-40/500D GEVT4 06 AB SV 20-40/500D GEVT5 06 AB SV 20-40/500D GEVT6 06 AB SV 10/100% GRC-S 06 SV 20-40/500D GEVT1 06 SV 20-40/500D GEVT2 06 ORANGE VALUE W/OP DDS ORANGE VALUE W/EPO DDS SV 20-40/500D GEVT3 06 SV 20-40/500D GEVT4 06 ORANGE VALUE W/ HI OP DDS SV 10/100% GRC-S 06 AB SV 20-40/500D GEVT5 06 SV 20-40/500D GEVT6 06 ORANGE VALUE SV 20-40/500D GEVT1 06 CB SV 20-40/500D GEVT2 06 CB SV 20-40/500D GEVT3 06 CB SV 20-40/500D GEVT4 06 CB SV 20-40/500D GEVT5 06 CB SV 20-40/500D GEVT6 06 CB SV 10/100% GRC-S 06 CB WELLS FARGO ADV 128 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit GW3 GWA GWD GWE GWJ GX3 GX5 GX9 GXA GXC GXD GXH GXJ GXL GXN GXO GXZ GY3 GY5 GY9 GYA GYC GYD GYE GYF GYH GYL GYN GYO GZ1 GZ3 GZ5 GZ9 GZA GZD GZH GZL GZN GZO H01 H02 H03 H04 H05 H06 H07 H08 H09 H10 H11 Plan / Benefit Description WELLS FARGO ADV COBRA SP 10/100% GIGANTE 07 ORANGE MEDICAL W/OP DDS ORNGE CLSC ENHNCD W/EPODDS WELLS FARGO ADV AB MCC ORANGE LO-PL SH07 MCC ORANGE HI-PL SH07 MCC ORANGE PLUS SH07 SV 20/80% GRC-S 06 SP 10/100% GULFSTRM 07 AB MCC ORANGE DELUXE SH07 MCC ORANGE HIGH SH07 SV 20/80% GRC-S 06 AB MCC ORANGE LOW SH07 MC COMP ORANGE SH07 MCC ORANGE PL-DLXE SH07 SV 20/80% GRC-S 06 CB MCC PRE ORNGE LO-PL SH07 MCC PRE ORNGE HI-PL SH07 MCC PRE ORNGE PLUS SH07 SP 10/100% GIGANTE 07 CB SV 15-30/80% 07 MCC PRE ORNGE DELUXE SH07 SV 15-30/80% 07 CB SV 15-30/80% 07 AB MCC PRE ORNGE HIGH SH07 MCC PRE ORNGE LOW SH07 MC COMP PRE ORNGE SH07 MCC PRE ORNGE PL-DLXE SH07 STAN. 10 ALLG.SER. COBRA MCC VALU ORNGE LO-PL SH07 MCC VALU ORNGE HI-PL SH07 MCC VALU ORNGE PLUS SH07 SP 10/100% GIGANTE 07 AB MCC VALU ORNGE DELUXE SH07 MCC VALUE ORANGE HIGH SH07 MCC VALU ORNGE LOW SH07 MC COMP VALUE ORANGE SH07 MCC VALU ORNGE PL-DLX SH07 DOMESTIC PARTNERSHIP PPO VISION CARE BENEFIT PPO FAMILY PLANING BENEFIT PPO 24/HOUR HEALTH INFO PPO HEARING AID BENEFIT PPO MENTAL NON-SMI PPO 90/70 MENTAL NON-SMI PPO 90/60 MENTAL NON-SMI PPO 90/50 MENTAL NON-SMI PPO 80/60 MENTAL NON-SMI PPO 80/50 MENTAL NONSMI INDEMNITY 80 129 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit H12 H13 H14 H15 H16 H17 H18 H19 H1J H1Z H20 H21 H22 H23 H24 H25 H26 H27 H28 H29 H2J H2Z H30 H31 H32 H33 H34 H35 H36 H37 H38 H39 H3J H3Z H40 H41 H42 H43 H44 H45 H46 H47 H48 H49 H4K H4S H4V H4W H4Y H4Z Plan / Benefit Description RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 2002 HMO STD PLAN 1 AB 2002 HMO STD PLAN 1 COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 2002 HMO STD PLAN 2 AB 2002 HMO STD PLAN 2 COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 2002 HMO STD PLAN 3 AB 2002 HMO STD PLAN 3 CBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 0/800A 3YRS DX GR-HA07 0/500A 3YRS PL GR-HA07 0/500A 2YRS GR-HA07 0/1300A 2YRS DX GR-HA07 0/1000A 2YRS P-EH GR-HR07 2003 STD 10/20 $200 COBRA 130 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit H50 H51 H52 H53 H54 H55 H56 H57 H58 H59 H5Z H60 H61 H62 H63 H64 H65 H66 H67 H68 H69 H6P H6Z H70 H71 H72 H73 H74 H75 H76 H77 H78 H79 H7L H7Z H80 H81 H82 H83 H84 H85 H86 H87 H88 H89 H8A H8B H8D H8E H8F Plan / Benefit Description RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 2003 STD 15/30 $400 COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 15-25/100A GR06 2003 STD 20/40 $600 COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 15/2000A EAR 3YRS GR-HA07 2003 HMO $20/$250 COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 0/500A 3YRS PL HA-SH08 0/1300A 3YRS DX HA-SH08 0/800A 3YRS DX HA-SH08 25/400A 3YRS HA-SH08 25/900A 3YRS PL HA-SH08 131 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit H8G H8J H8K H8L H8P H8Q H8R H90 H91 H92 H93 H94 H95 H96 H97 H98 H99 HA0 HA1 HA2 HA3 HA4 HA5 HA6 HA7 HA8 HA9 HAA HAB HAC HAD HAE HAF HAG HAH HAJ HAL HAN HAP HAR HAS HAT HAU HAV HAW HAX HB1 HB2 HB3 HBA Plan / Benefit Description 0/800A 3YRS HA-SH08 5/400A 3YRS HA-SH08 0/600A 2YRS HA-SH08 0/400A 3YRS HA-SH08 15-25/100A AARP GR08 25/1700A 3YRS DX HA-SH08 2000A/EAR 3YRS HA-GR08 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO HEARING AID BENEFIT HEARING AID BENEFIT HEARING AID BENEFIT HEARING AID BENEFIT HEARING AID - $800 PER AID HEARING AIDS $500 PER AID HEARING AID $500 - POS HEARING AID $1000 MAX/MBR HEARING AID (1 PER EAR) HEARING AID (1 EVERY 36MO) HI-OP MED W/O BSC DNT STAN HI-OP MED&DNT ALAME B-ONLY SANTA CLA H-O DNTL B ONLY HEARING AID $1000/$1500 HEARING AID $1000/$1500POS $500 HA (1 EVERY 36 MOS) $0 1AID PER EAR EVRY36MOS HEAR AID $1000 EVERY 3 YRS HEARING AID $500 EVERY 3YR HI-OP MED/DNTL ALAMEDA 300A/24M GR-VN07 HOMEMAKER 100H 1YR GR07 HEARING $500 PER EAR 12MO HEAR AID $750 PER AID 36MO H-O DTL SAN MATEO B ONLY HEAR AID 50%/$2000MAX 36MO HEAR AID 50% EVERY 24 MOS HEARING AID $2000/36 MONTH HEARING AIDE $600 RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT HI-OP DENTAL PLN BAY AREA 132 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit HBB HBC HBD HBY HCA HCB HCC HCE HCF HCH HCI HCJ HCL HCT HD2 HD3 HD6 HDA HDB HDC HDE HDF HDJ HDM HDN HDS HDW HE1 HE2 HE3 HE4 HE5 HE6 HE7 HEA HEB HED HEE HEF HEJ HEM HET HEV HEW HEX HEY HF6 HFA HFF HFJ Plan / Benefit Description HI DNTL BAY AREA-PRT B ONL BSC MED H-O DTL S.F. B ONL INCOMPLETE SH PLAN CODE STAND MED HIGH DENTAL-BAY HI MED/DNTL BAY PRT B ONLY HIGH MED CNTRAL PRT B ONLY HI-OP MED/DNTL CONTRA COST HIGH MED CENTRAL REGION SV 15-25/250A HCA 06 SV 15-25/250A HCA 06 CB HEALTH CREDITS INCENTIVE SV 15-25/250A HCA 06 AB HI-OP MED/DNTL SANTA CLARA H-OP M&D CNTR CSTA B ONLY SV 20-40/500A HUSD 05 SV 20-40/500A HUSD 05 CB $5/$400A 3YRS HREXAM+AID06 HI-OP DNTL-SAN DIEGO PRT B HI-OP DNT SAN DIEGO B ONLY HIGH OPTION DENTAL-CENTRAL 300A 2YRS HA-GR08 SV 15-25/250A HCA 07 SV 20-40/500A HUSD 05 AB HOME DELVD MEALS 30 GR07 HIGH OPTION DENTAL- NORTH HIGH OPTION DENTAL - SOUTH LADWP CUSTOM HEARING AID SR PLAN/PLUS HEARING SR PLUS HEARING - SO CAL RG HEARING PREMIER CUSTOM RETIREE GOLD HEARING GM CUSTOM HEARING RETIREE GOLD HEARING RETIREE HEARING AID CUSTOM SV 10/100% HEMET 07 BSC MED/H-O DTL ALAM B ONL HI-OP MED/BSC DNTL ELDORAD SV 20/200A HUGHES ELEC SV 20/200A HUGHES ELEC CB SV 20/200A HUGHES ELEC AB SV 10/100% HUSD 05 CB SV 10/350A HLTHCARE 05 CB SV 20/350A HTAU 05 CB SV 20-40/500A HP 07 SV 20-40/500A HP 07 CB SV 20-40/500A HP 07 AB $25/$400 3YRS HREXAM+AID06 SV 10/100% HEMET 07 CB SV 15-25/250A HCA 07 CB SV 10/100% HEATFROST 05 AB 133 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit HFR HGA HGF HHE HHF HHH HIB HIP HJB HJF HJQ HK8 HKA HKB HKE HKF HKV HLA HLB HLC HLD HLF HLH HLJ HLP HLS HM1 HM2 HM3 HM4 HM5 HM6 HM7 HMA HMB HMC HMD HMF HMJ HMN HMO HMR HMT HMX HMY HMZ HNA HNB HNC HND Plan / Benefit Description SV 10/100% HEATFROST 05 SV 10/100% HEMET 07 AB SV 10/100% HEATFROST 07 500A 3YRS HA-GR08 SV 15-25/250A HCA 07 AB UNLIMITED 1AID/EAR HA-GR08 HI-DNTL POS IMPERIAL PRT B HI-DNTL CHOICE IMPERIAL SAN JOAQ B-ONLY HI-OP MED SV 10/100% HEATFROST 07 CB SAN JOAQUIN HI-OP MED 500A 3YRS 0PREM HA-GR08 HI-OP DNTL-KERN PART B HI-DNTL POS KRN/VNTRA PT B HI-OP DNTL-KERN BASIC SV 10/100% HEATFROST 07 AB HI-DNTL CHOICE KERN/VNTURA HI-OP DNTL-LA,OR,SB,RIV HI-OP BSC DTL B ONLY EL DO HI-OP DTL LA/RV/SB PART B HI-OP MED W/O BSC DTL ELDO SV 10/100D HACIENDA 07 SV 10/100D HACIENDA 07 CB SV 15-25/250A HCA INC AB SV 15-25/250A HCA INC LACERS CUSTOM HEARING AID 2002 HMO STD PLAN 1 2002 HMO STD PLAN 2 2002 HMO STD PLAN 3 2003 STD 10/20 $200 2003 STD 15/30 $400 2003 STD 20/40 $600 2003 HMO $20/$250 HI-OP MED-BASIC DTL SONOMA MARIN PRT B ONLY HI-MED SV 15-25/250A HCAMN 06 SVA 20-40/250A HM 06 SV 15-25/250A HCAMN 06 CB SV 15-25/250A HCAMN 06 AB H-OP BASIC DTL SONOMA-B ON MONTEREY HI-MED MARIN HI-OP MED NO BSC DTL HI-OP M&D SAN MATEO B ONLY SVA 20-40/250A HM 06 AB MONTEREY PRT B ONLY HI-MED SVA 20-40/250A HM 06 CB NAPA PRT B ONLY HI-MED HI-OP MED SACTO/ELDR PRT B HI-OP MED SACTO/EL DORADO HI-OPT DENTAL SAN DIEGO CO 134 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit HNH HNP HOA HOB HOC HOE HOI HOK HOM HON HOS HPA HPB HPC HPE HPF HPG HPJ HPK HPL HPS HPX HPZ HQA HR0 HR1 HR2 HR3 HRA HRB HRD HRE HRF HRG HRI HRJ HRL HRM HRN HRP HRR HRS HRY HSA HSB HSC HSD HSE HSJ HSL Plan / Benefit Description SV 10/100D HACIENDA 07 AB NAPA HI-OP MED NO BSC DTL RESERVED HEARING PFFS HI-OPT DNTL - O.C. B ONLY HI-OPT DNTL - ORANGE CO. RESERVED HEARING PFFS RESERVED HEARING PFFS 10/300A 3YRS MAX GR-HA07 HI-OPT DENTAL CENTRAL CA HI-OP DNTL NORTHERN CALIF HI-OP DNTL SOUTHERN CALIF. SV HPA $15/$30/$500 SV HPA $15/$30/$500 CB SV 15-40/500A HP 06 RESERVED PFFS SV 15-30/500A HP 06 20-40/500A HP GR07 SV HPA $15/$30/$500 AB 20-40/500A HP NO-AARP GR08 SV 15-25/250A HCA INC CB PLA/SANJ HI-OP MED NO DTL SV 15-30/500A HP 06 AB SV 15-30/500A HP 06 CB SP 20/250A HAZARD CO 07 HEARING AID 1PR/EAR Q 36MO HRNG AID CSTM $750 P/EAR HRING AID $500 ALLOWANCE HRING AID $300 ALLOWANCE HI-OP DNTL CNTR CSTA B ONL 0/500A 3YRS SH-HA07 0/800A 3YRS DX SH-HA07 5/400A 3YRS SH-HA07 25/400A 3YRS SH-HA07 SH INDIV. HEARING PPO HEARING AID RIDER 0/800A 3YRS SH-HA07 25/900A 3YRS PL SH-HA07 25/1700A 3YRS DX SH-HA07 CODE CAN BE USED AGAIN . 0/500A 3YRS PL SH-HA07 300A GR-HA07 CODE CAN BE USED AGAIN . 0/1300A 3YRS DX SH-HA07 HI-OP MED-SBB/SLO PRT B HI-OP MED SBB/SLO HI-OP MED/DNTL BAY AREA HI-OP DNTL-SAN DIEGO BASIC H-OP MD/DT B ONLY SANT CLA HI-MED SJA/PLA PRT B ONLY HI-OP DNTL-IMPERIAL BASIC 135 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit HSM HSN HSO HSP HSR HSS HST HSZ HTA HTB HTC HTE HTF HTJ HTU HUA HUB HUF HUJ HUS HUT HUV HVA HVB HVC HVD HVE HVJ HVT HWA HWD HXA HXB HXC HXD HXE HYA HYB HYC HYD HYG HYJ HYX HYZ HZ1 HZA HZB HZC HZG HZX Plan / Benefit Description HI-OP MED/DTL SAN MATEO SOL./SON.HI-MED PRT B ONLY SONO/SOL HI-OP MED NO DTL CHOICE HI-OP DNTL SOUTHERN HI-MED SNTA CRZ PRT B ONLY HI DNTL IMPERL PRT B ONLY HI-OP MED/DNTL SANTA CLARA SANTA CRUZ HI-MED HI-OP MED STANISLAUS HI-OP MED.-STNSLAUS PRT B 500A 2YRS HA-GR08 SV 5/350A HCT/AMR UN 05 CB SV 10/100% HEATFROST 05 CB SV 5/350A HCT/AMR UN 05 AB SV 5/350A HCT/AMR UNION 05 SP 20/250A HAZARD CO 07 CB HI-OP MED/WO-BSC DTL STANI HEARING AID 50% $2000 MAX SV 10/100% HUSD 05 AB SV 10/100% HUSD 05 SV 10/350A HEALTHCARE 05 SV 20/350A HTAU 05 HI-OP DNTL-KRN/VNT PRT B HI-OP DNTL-VENTURA B-ONLY VEBA HA (1EVERY 24 MONTHS) LADWP HEARING AID GR08 HI-OP DNTL-VENTURA BASIC SV 20/350A HTAU 05 AB HI-OP DNTL-VENTURA BASIC SP 20/250A HAZARD CO 07 AB UNLIMITED 3YRS HA-GR08 SV 20-40/90% HP 08 SV 10/100% HEMET 07 SV 20-40/90% HP 08 CB 1000A 3YRS HA GR08 SV 20-40/90% HP 08 AB SV 10/100% HEMET USD 06 SV 10/100% HEMET 07 CB HEARING AID - $2500 MAX 1PR/EAR 3YRS HA-GR08 SP 15/100% HAZARD CO 06 CB SV 10/350A HLTHCARE 05 AB SV 10/100% HEMET USD 06 AB SV 10/100% HEMET USD 06 CB STANDARD 5 PLAN (COBRA) SV 20-40/500A HEM USD06 SV 10/100% HEMET 07 AB SP 15/100% HAZARD CO 06 SP 15/100% HAZARD CO 06 AB SV 20-40/500A HEM USD06 AB 136 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit HZZ I00 I01 I02 I03 I04 I05 I06 I07 I08 I09 I0A I0B I0C I0D I0E I0F I0G I0H I0J I0K I0L I0M I0N I0P I0Q I0R I0S I0T I0U I0X I0Z I10 I1M I1Q I1R I1S I1T I1U I1Z I20 I2Q I2R I2S I2T I2U I2Z I30 I3Q I3R Plan / Benefit Description SV 20-40/500A HEM USD06 CB INDEMNITY COVERAGE INDEMNITY PLAN W/PPO INDEMNITY PLAN NO/PPO IND./ARC HMO BEN./UFCW BIS IND./F1C BEN./DAIRY MERCED INDEMNITY PPO-90/70 INDEMNITY PPO-90/70 COPAY INDEMNITY PPO-80/60 INDEMNITY PPO-80/60 COPAY INDEMNITY PPO-90/80 COPAY INDEMNITY PLAN/WITH PPO INDEMNITY PLAN/NO PPO INDEMNITY/SMALL GROUP PPO INDEMNITY SMALL GROUP PPO INDEMNITY SMALL GROUP PPO SMALL GROUP PPO $250 DED. SMALL GROUP PPO $500 DED. SMALL GROUP PPO $1000 DED. KEENAN HIPC INDEMNITY KEENAN HIPC PPO AFFORDABLE PPO 250 SMALL SM GRP PPO 250 OUT OF STAT INDEMNITY NATIONAL PPO INDEMNITY PPO-CUSTOM ELITE PPO 250 ELITE PPO 500 ELITE OOS INDEMNITY PREMIER PPO 500 PREMIER OOS INDEMNITY INDEMNITY PLAN-NO PPO KEENAN HIPC PPO IHS PPO (AFFORDABLE NET) IMPERIAL STANDARD PLAN ELITE PPO 250 COBRA ELITE PPO 500 COBRA ELITE OOS INDEMNITY COBRA PREMIER PPO 500 CBRA PREMIER OOS INDEMNITY CBR IHS PPO (AFFORDABLE NET) IHS INDEMNITY ELITE PPO 250 CAL COBRA ELITE PPO 500 CAL COBRA ELITE OOS INDEMNITY CCOBRA PREMIER PPO 500 CAL CBRA PREMIER OOS INDEMNITY CCBR IHS INDEMNITY (COBRA) INDEMNITY-SELF FUNDED ELITE PPO 250 FED CBR EXT ELITE PPO 500 FED CBR EXT 137 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit I3S I3T I3U I3Z I40 I4Q I4R I4S I4T I4U I4Z I5Q I5R I5S I5T I5U I6J I6Q I6R I6S I6T I6U I81 IA0 IAA IAD IAJ IAZ IBA IBD IBJ IBP IBX IBZ IC2 IC3 ICB ICE ICF ICH ICI ICJ ICK ICP ICX ICZ IDB IDT IDZ IEA Plan / Benefit Description ELITE OOS FED CBR EXTENDED PREM PPO 500 FED CBR EXTEN PREM OOS FED CBR EXTENDED INDEMNITY SELF FUNDED COBR DUMMY PLAN-NOT IN USE ELITE PPO 250 FED CBR DISA ELITE PPO 500 FED CBR DISA ELITE OOS FED CBR DISABLED PREM PPO 500 FED CBR DISAB PRE OOS FED CBR DISABLED DUMMPY PLAN-NOT IN USE ELITE PPO 250 CAL CBR EXT ELITE PPO 500 CAL CBR EXT ELITE OOS CAL CBR EXTENDED PREM PPO 500 CAL CBR EXTEN PREM OOS CAL CBR EXTENDED SV 20/250A+20% IC06 ELITE PPO 250 CAL CBR DISA ELITE PPO 500 CAL CBR DISA ELITE OOS CAL CBR DISABLED PREM PPO 500 CAL CBR DISAB PREM OOS CAL CBR DISABLED IND.CONV.PLAN-880 ARMSTRONG INDEMNITY SV 15/100% SCIBEW 06 SV 30-40/250A ITT 06 CB SV 30-40/250A ITT 06 AB ARMSTRONG INDEMNITY-COBRA SV 20/100% IBEW 06 INFERTILITY BASIC D&T ITT AB IMPERIAL CHOICE-PRT B ONLY SV 20/100% IBEW 06 AB SV 20/100% IBEW 06 CB INDIV CONVERSION $15 IC PLAN $35/30% IMPERIAL CNTY PRT B ONLY SV 35/70% IP05 SV 15-30/100% ICIPT 06 SV 35/70% IC06 SV 15-30/100 ICIPAINTS SV 15-30/100 ICIPAINTS AB SV 15-30/100% ICIPT 06 CB SV 15-30/100 ICIPAINTS CB SV 15-30/100% ICIPT 06 AB INDEMNITY 80/20 $250 D CBR SV 20-30/250A INGRAM 08 INDEMNITY DENTAL INDEMNITY 80/20 $500 D CBR SV 15/100% SCIBEW 06 CB 138 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit IEB IED IEJ IF6 IFA IFB IFC IFD IFE IFF IFG IFH IG4 IG5 IG6 IG7 IG8 IG9 IGB IGC IGD IGF IGG IGH IGQ IH2 IH3 IH4 IH5 IH6 IH7 IHE II0 IIE IIZ IJE IK1 IK2 IKA IKC IKD IKJ IKM IKX IL1 ILA ILB ILC ILD ILG Plan / Benefit Description SV 20-30/250A INGRAM 08 CB SV 35-45/250A ITT 06 CB SV 35-45/250A ITT 06 AB INFERTILITY EDISON INTL 06 INFERTILITY SCS VEBA 06 INFERTILITY ALAMEDA 06 INFERTILITY SCS VEBA 06 INFERTILITY SCS VEBA 06 INFERTILITY SCS VEBA 06 INFERTILITY SCS VEBA 06 INFERTILITY L3 ELECTRON 06 INFERTILITY DX ONLY 06 SV IND HMO20-35/80% GBHIPA SV IND HMO10-35/250D GBHIP SV IND HMO10-35/250D GBHIP SV IP 20-35/80% GBILLHIPA SV IP $35/70% GBILL HIPPA SV 35/50%A GB HIP IP05 SV 20-30/250A INGRAM 08 AB SV IND HMO10-35/250D GBILL SV IND HMO20-35/80% G-BILL SV IND HMO10-35/250D GBILL SV IP 20-35/80% GBILLED SV IP $35/70% GRP BILLED SV 35/50%A GBILL IP05 INDIV $10/$30/$250A HIPPA INDIV $10/$30/$250A HIPPA2 INDIV $10/$30/$250A HIPPA3 INDIV $15/$30/80% HIPPA INDIV $15/$30/80% HIPPA 2 INDIV $15/$30/80% HIPPA 3 SV 20/100% IAP WS 07 IHS PPO (PCCA NETWORK) SV 20/100% IAP WS 07 CB IHS PPO-COBRA PCCA NETWORK SV 20/100% IAP WS 07 AB IKON 15/250 PLAN IKON 15/250 PLAN COBRA SV 15/100% SCIBEW 06 AB SV 20/250A+80% IK 06 SV 5/100% ITT 06 CB SV 5/100% ITT 06 AB SV 20/250A+80% IK 06 CB SV 20/250A+80% IK 06 AB INDEMNITY CUSTOM 500 SV 25-35/450A INTPUB 07 SV 25-35/450A INTPUB 07 CB INDEMNITY 80/20 $250 DED INDEMNITY 80/20 $500 DED SV 25-35/450A INTPUB 07 AB 139 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ILZ IM1 IM2 IM3 IM4 IM5 IM6 IM7 IM8 IMA IMB IMP IOA IP1 IP2 IP3 IP4 IP5 IP6 IP7 IP8 IP9 IPA IPB IPC IPD IPF IPG IPH IPQ IPR IPS IPT IPU IRD IRJ IRX IS1 ITA ITB ITJ ITR ITT ITV ITX ITY ITZ IUF IVN IZ0 Plan / Benefit Description INDEMNITY CUSTOM 500 CBR SH IMPERIAL STD MED SH IMPERIAL STD W/ HI DEN SH IMPERIAL PART B STD MED SH IMPERIAL PT B W/ HI DEN SH IMPERIAL PLUS PLAN MED SH IMPERIAL PLUS W/ HI DEN SH IMPERIAL PART B PLUS SH IMPERIAL B PLS & HI DEN IMPERIAL STANDARD PLAN IMPERIAL STND PRT B ONLY IMPERIAL CHOICE PLAN INDEMNITY PLAN/WITH PPO SV 20-35/80% HP06 SV 35/70% HP06 SV 10-35/250D HP06 SV IND HMO20-35/80% HIPPA SV IND HMO10-35/250D HIPPA SV IND HMO10-35/250D HIPPA SV IP 20-35/80% HIPPA SV IP $35/70% HIPPA SV 35/50%A HIPPA IP05 INDIVIDUAL $10/$30/$250A INDIVIDUAL $15/$30/80% SV IND HMO10-35/250D SV IND HMO20-35/80% SV IND HMO10-35/250D SV IP 20-35/80% SV IP $35/70% SV 35/50%A IP05 SV 35/50% IP06 SV 20-35/80% IP06 SV 35/70% IP06 SV 10-35/250D IP06 SV 25-35/250A ITT 06 CB SV 25-35/250A ITT 06 AB IND RX VIA PRSCRPTN SOL IND.CONV.PLAN-STANDARD SP ITT SP 20/100% ITT 06 SP ITT AB PPO INFERTILITY TX RIDER ITT SP 20/100% ITT 06 CB SP 20/100% ITT 06 AB SP ITT CB ITT COBRA INFERTILITY $0 UFCW 06 INDEMNITY VISION INDEMNITY COVERAGE 140 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit IZ1 IZ2 IZ3 IZ4 IZ5 IZ6 IZ7 IZ8 IZ9 IZA IZB IZC IZD IZE IZF IZG IZH IZJ IZK IZL IZM IZN IZO IZP IZQ IZT IZU IZV IZX J0Q J0R J0S J0T J0U J1C J1I J1P J1Q J1R J1S J1T J1U J1Y J1Z J2P J2Q J2R J2S J2T J2U Plan / Benefit Description INDEMNITY PLAN W/PPO COBRA INDEMNITY PLAN NO/PPO COBR IND./ARZ HMO BEN./UFCW BIS IND./F1Z BEN./DAIRY MERCED INDEMNITY PPO-90/70 INDEMNITY PPO-90/70-COPAY INDEMNITY PPO-80/60 INDEMNITY PPO-80/60 COPAY INDEMNITY PPO-90/80 COPAY INDEMNITY PLAN/WITH PPO CB INDEMNITY PLAN/NO PPO CBR INDEMNITY SMALL GROUP/PPO INDEMNITY SMALL GROUP/PPO INDEMNITY SMALL GROUP/PPO SMALL GROUP PPO $250 DED. SMALL GROUP PPO $500 DED. SMALL GROUP PPO $1000 DED. KEENAN HIPC INDEMN. COBRA KEENAN HIPC PPO COBRA AFFORDABLE PPO 250 SMALLCB SM GRP PPO250 OUT/STATE CB INDEMNITY NATIONAL PPO INDEMNITY PLN NO PPO CC INDEMNITY PPO-CUSTOM INDEMNITY PLAN W/PPO CC SMALL GROUP PPO $250DED CC SMALL GROUP PPO $500DED CC SMALL GRP PPO $1000DED CC CNDEMNITY (NON PPO) COBRA ELITE PPO 250 7/00 ELITE PPO 500 7/00 ELITE OOS INDEMN 7/00 PREMIER PPO 500 7/00 PREMIER PPO 500 (80/60) 880 PLAN II INDIVIDUAL CONVERSION 880 880 PLAN ELITE PPO 250 7/00 COBRA ELITE PPO 500 7/00 COBRA ELITE OOS INDEMN 7/00 CBR PREMIER PPO 500 7/00 CBRA PREM PPO 500 (80/60) COBRA 880 PLAN COBRA 880 PLAN COBRA II MFP 880 PLAN ELITE PPO 250 7/00 CCOBRA ELITE PPO 500 7/00 CCOBRA ELITE OOS INDEMN 7/00 CCBR PREMIER PPO 500 7/00 CCBRA PRM PPO 500(80/60) CAL CBR 141 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit J2Y J3Q J3R J3S J3T J3U J4Q J4R J4S J4T J4U J5Q J5R J5S J5T J5U J6Q J6R J6S J6T J6U JAA JAJ JAZ JB7 JBA JBF JBJ JBT JBX JBZ JDF JJA JJJ JJN JJY JJZ JNJ JPA JPC JPF JPG JPJ JPK JPL JPM JPN JPS JPX JPZ Plan / Benefit Description MFP 880 PLAN - COBRA ELITE PPO 250 FED CBR EXT ELITE PPO 500 FED CBR EXT ELITE OOS FED CBR EXTENDED PREM PPO 500 FED CBR EXTEN PR PPO 500(80/60) FD CB EX ELITE PPO 250 FED CBR DISA ELITE PPO 500 FED CBR DISA ELITE OOS FED CBR DISABLED PREM PPO 500 FED CBR DISAB PR PPO 500(80/60) FD CB DS ELITE PPO 250 CAL CBR EXT ELITE PPO 500 CAL CBR EXT ELITE OOS CAL CBR EXTENDED PREM PPO 500 CAL CBR EXTEN PR PPO 500(80/60) CL CB EX ELITE PPO 250 CAL CBR DISA ELITE PPO 500 CAL CBR DISA ELITE OOS CAL CBR DISABLED PREM PPO 500 CAL CBR DISAB PR PPO 500(80/60) CL CB DS SV 20-30/250A JPMCC 06 SV 20-30/250A JPMCC 06 AB SV 20-30/250A JPMCC 06 CB SV 20-40/400A JTBENTRST CB SV 20-40/400A JBT 06 SV 15-35/250A J&J 07 SV 20-40/400A JTBENTRST AB SV 20-40/400A JTBENTRST SV 20-40/400A JBT 06 AB SV 20-40/400A JBT 06 CB SV 15-35/250A J&J 07 CB SV 15-35/250A J&J 06 SV 15-35/250A J&J 06 AB SV J&J NUTRO 15-35/250A SV 15-35/250A J&J 06 CB SV J&J NUTRO 15-35/250A CB SV J&J NUTRO 15-35/250A AB SVA 10/100% JPGT 06 SV 20-30/250A JPMCC 07 SV 20-30/250A JPMCC 07 CB SV 20/100% JP GETY 06 SV 20-30/250A JPM AB SV 20-30/250A JPMCC 07 AB SVA 10/100% JPGT 06 CB SV 20-30/250A JPM SV 20-30/250A JPM CB SVA 10/100% JPGT 06 AB SV 20/100% JP GETY 06 AB SV 20/100% JP GETY 06 CB 142 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit JRF JUA JUJ JUZ JZ2 JZ3 JZ4 JZ5 JZ6 JZ7 JZ8 JZ9 JZA K1D K1E K1F K1G K1N K1P K1R K1S K1W K1Y K1Z K22 K23 K24 K25 K2C K2K K2V K2Z K32 K33 K34 K35 K3C K3J K3Z K42 K43 K44 K45 K4N K5N KA2 KA3 KA4 KA5 KA6 Plan / Benefit Description SV 15-35/250A J&J 07 AB SVA 10/500D 05 SVA 10/500D 05 AB SVA 10/500D 05 CB SP 15/250A SG06 CB SP 15/250A SG06 AB SP 15/250A SG06 CC SP 15/250A SG06 CE SP 15/250A SG06 CD SP 15/250A SG06 FE SP 15/250A SG06 FD SP 15/250A SG06 US SP 15/250A SG06 ELITE 80 FED CBR DISABLED ELITE 80 FED CBR EXTENDED ELITE 80 CAL CBR EXTENDED ELITE 80 CAL CBR DISABLED KERN STANDARD PLAN 10/80 PLAN (POS) ELITE 80 CAL COBRA ELITE 80 ELITE 80 COBRA 10/80 PLAN - POS (COBRA) INACTIVE KEC KERN CG GR07 KEC KERN LOW CG GR07 KEC KERN HI CG GR07 KEC KERN DX CG GR07 MFP 10/80 PLAN DUMMY DUMMY MFP 10/80 PLAN-COBRA KEC KERN CGII GR07 KEC KERN LOW CGII GR07 KEC KERN HI CGII GR07 KEC KERN DX CGII GR07 STANDARD $10/80 PLAN STANDARD $10/80 PLAN AB STANDARD $10/80 PLAN COBRA KEC KERN CGEH GR07 KEC KERN LOW CGEH GR07 KEC KERN HI CGEH GR07 KEC KERN DX CGEH GR07 KERN STANDARD W/OPT DENTAL KERN STANDARD W/HI DENTAL RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 143 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit KA7 KA8 KA9 KAA KAB KAD KAH KAJ KAL KAN KB2 KB3 KB4 KB5 KB6 KB7 KB8 KB9 KBA KBB KBC KBD KBG KBH KBJ KBL KBN KBP KCA KCB KCC KCD KCH KCJ KCP KD2 KD3 KD4 KD5 KD6 KD7 KD8 KD9 KDA KDB KDD KDE KDG KDJ KE2 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO SV 10/100% 06 SV 10/100% 06 CB MCC KERN DELUXE SH07 MCC KERN HIGH SH07 SV 10/100% 06 AB MCC KERN LOW SH07 MC COMP KERN SH07 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20-30/90% IKON 08 SV 10/100% PUBSECTR 06 SV 10/100% PUBSECTR 06 CB MCC ESS KERN DELUXE SH07 SV 15-25/10% KARYKEI 07 MCC ESS KERN HIGH SH07 SV 10/100% PUBSECTR 06 AB MCC ESS KERN LOW SH07 MC COMP ESS KERN SH07 KRN/VNTRA PRTB ONLY-CHOICE SV 20-30/90% IKON 08 CB KEENAN COMP KERN GR07 CODE CANCELLED-DO NOT USE CODE CANCELLED-DO NOT USE KERN CLASSIC I W/HIOP DDS CODE CANCELLED-DO NOT USE KERN CLASSIC I W/EPO DDS RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20-30/90% IKON 08 AB KEC KERN LOW GR07 CODE CANCELLED-DO NOT USE CODE CANCELLED-DO NOT USE SV 15-25/10% KARYKEI 07 CB CODE CANCELLED-DO NOT USE RESERVED PPO 144 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit KE3 KE4 KE5 KE6 KE7 KE8 KE9 KEB KEF KF2 KF3 KF4 KF5 KF6 KF7 KF8 KF9 KFB KFI KG2 KG3 KG4 KG5 KG6 KG7 KG8 KG9 KGF KGH KGL KGW KGX KH8 KH9 KHA KHJ KHZ KJ2 KJ3 KJ4 KJ5 KJ6 KJ7 KJ8 KJ9 KK6 KKA KKB KKD KKF Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO KEC KERN HIGH GR07 SP 10/100% KNAPP 06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO KEC KERN DELUXE GR07 FREEDOM PLAN 108 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SP 10/100% KNAPP 06 CB ARP MCC KERN HI SH08 ARP MCC KERN LO SH08 ARP MCC KERN SH08 ARP MCC KERN DLX SH08 RESERVED PPO RESERVED PPO SV 20/100% 06 SV 20/100% 06 AB SV 20/100% 06 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 15-25/90% KARYK 06 SV 15/100% 05 SV 20-30/250A IKON 07 SV 20-30/250A IKON 07 CB SV 20-30/250A IKON 07 AB 145 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit KKJ KKX KKY KKZ KL2 KL3 KL4 KL5 KL6 KL7 KL8 KL9 KLA KLB KLG KLJ KM2 KM3 KM4 KM5 KM6 KM7 KM8 KM9 KMD KME KMH KMS KN1 KN2 KN3 KN4 KN5 KN6 KN7 KN8 KNE KP5 KP6 KPJ KQF KR2 KR3 KR4 KR5 KR6 KR7 KR8 KR9 KRC Plan / Benefit Description SV 15/100% 05 AB SV 15-25/90% KARYK 06 AB SV 15-25/90% KARYK 06 CB SV 15/100% 05 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SP 10/100% 06 SP 10/100% 06 CB SV 15-25/10% KARYKEI 0 AB SP 10/100% 06 AB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO KERN MEDICAL W/OP DDS KERN MEDICAL W/EPO DDS KERN MEDICAL W/HI OP DDS KERN MEDICAL SH KERN STD MED SH KERN STD MED W/ HI DEN SH KERN PART B STD MED SH KERN PART B W/ HI DEN SH KERN PLUS MED SH KERN PLUS MED W/ HI DEN SH KERN PART B PLUS MED KERN PART B PLUS W/ HI DEN ENDORSE KERN BAS W/ NO DEN SV $10-$20/80% SV $10-$20/80% CB SV $10-$20/80% AB SP 10/100% KNAPP 06 AB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/80 PLAN 146 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit KRZ KS2 KS3 KS4 KS5 KS6 KS7 KS8 KS9 KSA KSJ KSL KSM KSR KSX KSZ KT2 KT3 KT4 KT5 KT6 KT7 KT8 KT9 KU2 KU3 KU4 KU5 KU6 KU7 KU8 KU9 KV2 KV3 KV4 KV5 KV6 KV7 KV8 KV9 KVP KW2 KW3 KW4 KW5 KW6 KW7 KW8 KW9 KWD Plan / Benefit Description 10/80 PLAN COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20/500A KSL 06 SV 20/500A KSL AB SV 20/500A KSL KERN CLASSIC I SV 20/500A KSL CB SV 20/500A KSL 06 AB SV 20/500A KSL 06 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO KERN/VENTURA BASIC CHOICE RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO KERN CLASSIC I W/OP DDS 147 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit KX2 KX3 KX4 KX5 KX6 KX7 KX8 KX9 KY2 KY3 KY4 KY5 KY6 KY7 KY8 KY9 KZ1 KZ2 L01 L02 L03 L04 L05 L06 L07 L08 L09 L0J L10 L11 L12 L13 L14 L15 L16 L17 L18 L19 L1A L1C L1D L1E L1F L1G L1J L1R L1S L1W L1Z L20 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RWELL/PREF-50-OPMH COBRA STANDARD 10 - $25 ER COBRA LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN SV 15/100A LA MACHINIST AB LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFELINK CRISIS CM LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LOS ANGELES STANDARD PLAN STANDARD 20 PLAN ELITE 20 FED CBR DISABLED ELITE 20 FED CBR EXTENDED ELITE 20 CAL CBR EXTENDED ELITE 20 CAL CBR DISABLED SV 25/100A LA MACHINIST AB ELITE 20 PLAN CAL CBRA ELITE 20 PLAN ELITE 20 PLAN CBRA STANDARD 20 PLAN COBRA LIFE COVERAGE PLAN 148 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit L21 L22 L23 L24 L25 L26 L27 L28 L29 L2A L2B L2D L2E L2F L2G L2H L2J L2R L2S L2W L2Z L30 L31 L32 L33 L34 L35 L36 L37 L38 L39 L3A L3C L3G L3H L3J L3L L3M L3N L3P L3Q L3T L3U L3X L3Y L3Z L40 L4A L4C L4G Plan / Benefit Description LIFE PLAN W/SEATBELT RIDER LIFE PLAN W/SEATBELT RIDER LIFE PLAN W/SEATBELT RIDER LIFE PLAN W/SEATBELT RIDER LIFELINK FOCUS CM 25 LIFE PLAN W/SEATBELT RIDER LIFE PLAN W/SEATBELT RIDER LIFE PLAN W/SEATBELT RIDER LIFE PLAN W/SEATBELT RIDER KEC 1 LA CG GR07 KEC 1 LA CGII GR07 PREMIER 20 FED CBR DISABLE PREMIER 20 FED CBR EXTEND PREMIER 20 CAL CBR EXTEND PREMIER 20 CAL CBR DISABLE KEC 1 LA CGEH GR07 STANDARD $10-$20/80 AB PREMIER 20 PLAN CAL CBRA PREMIER 20 PLAN PREMIER 20 PLAN CBRA STANDARD $10-$20/80 COBRA LIFE PLAN W/SEATBELT RIDER LIFE PLAN W/SEATBELT RIDER LIFE PLAN (SMALL GRP) LIFE PLAN (SMALL GRP) LIFE PLAN (SMALL GRP) LIFELINK FOCUS CM 35 LIFE PLAN/SEATBELT (SMALL) GROUP LIFE ELITE GROUP LIFE ELITE SMALL GROUP LIFE LOS ANGELES PLUS PLAN HMO 20 PLAN SP 10/100% L3/CS 06 SV 20-30/100D L3 ELEC 06 HMO 20 PLAN AB KEC 1 LA LO CG GR07 SV 20-30/100D L3 ELE 06 CB KEC 1 LA LO CGII GR07 SP 10/100% L3/CS 06 AB KEC 1 LA LO CGEH GR07 SV 15/100% L3ETI 05 CB HMO 20 PLAN USERRA SV 20-30/100D L3 ELE 06 AB SP 10/100% L3/CS 06 CB STANDARD $15-$30/80 COBRA GROUP LIFE PREMIER LOS ANGELES STD. W/OPT DDS HMO 20 PLAN CBRA KEC 1 LA LO-PL CG GR07 149 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit L4H L4J L4K L4L L4M L4X L4Z L50 L51 L52 L53 L54 L55 L56 L57 L58 L59 L5A L5C L5E L5F L5G L60 L61 L62 L63 L64 L65 L66 L67 L68 L69 L6A L6C L6E L6F L6G L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L7A L7C L7E Plan / Benefit Description SV 15/100% L3 ELEC 06 STANDARD $20-$40/$250A AB KEC 1 LA LO-PL CGII GR07 KEC 1 LA LO-PL CGEH GR07 SV 15/100% L3 ELEC 06 CB SV 15/100% L3 ELEC 06 AB STANDARD $20-$40/$250A CBR DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY LOS ANGELES STAND W/HI DNT HMO 20 PLAN CAL CBRA KEC 1 LA HI CG GR07 KEC 1 LA HI CGII GR07 KEC 1 LA HI CGEH GR07 DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY INACTIVATED DUMMY DUMMY DUMMY DUMMY LOS ANGELES PLUS W/OPT DDS HMO 20 FED CBR DISABLED KEC 1 LA HI-PL CG GR07 KEC 1 LA HI-PL CGII GR07 KEC 1 LA HI-PL CGEH GR07 DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY DUMMY LOS ANGELES PLUS W/HI DNTL HMO 20 FED CBR EXTENDED KEC 1 LA PL CG GR07 150 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit L7F L7G L8C L8E L8F L8G L93 L95 L99 L9C L9D L9E L9F L9G L9H L9L L9N L9O LA0 LA1 LA2 LA3 LA4 LA5 LA6 LA7 LA8 LA9 LAA LAB LAC LAD LAE LAF LAG LAH LAJ LAK LAM LAN LAP LAR LAS LAT LAU LAZ LBA LBB LBD LBG Plan / Benefit Description KEC 1 LA PL CGII GR07 KEC 1 LA PL CGEH GR07 HMO 20 CAL CBR EXTENDED KEC 1 LA DX CG GR07 KEC 1 LA DX CGII GR07 KEC 1 LA DX CGEH GR07 MCC VALUE LA LO-PL SH07 MCC VALUE LA HI-PL SH07 MCC VALUE LA PLUS SH07 HMO 20 CAL CBR DISABLED MCC VALUE LA DELUXE SH07 KEC 1 LA PL-DX CG GR07 KEC 1 LA PL-DX CGII GR07 KEC 1 LA PL-DX CGEH GR07 MCC VALUE LA HIGH SH07 MCC VALUE LA LOW SH07 MC COMP VALUE LA SH07 MCC VALUE LA PL-DLXE SH07 ACE PARKING SH LOS ANGELES STD MED LOS ANGELES STD W/ HI DEN LOS ANGELES PART B STD MED LOS ANGELES PT B W/ HI DEN SH LOS ANGELES PLUS MED LOS ANGELES PLUS W/ HI DEN LOS ANGELES PART B PLUS LOS ANGELES B PL W/ HI DEN ACE PARKING COBRA LA COUNTY-PART B ONLY LOS ANGELES PHAN B ONLY LOS ANGELES BASIC PLAN 20-30/250A LOKHEED GR06 ENDORSE LA BASIC W/ NO DEN SV 25/100A LA MACHINIST SV 25/100A LA MACHINIST CB SP 10/100% LARISA 06 LAUSD $10/100% AB SP 10/100% LARISA 06 CB SV 15/100A LA MACHINIST SV 15/100A LA MACHINIST CB LOS ANGELES PHAN SP 10/100% LARISA 06 AB LAUSD $5 GRP RETIREE SPT 10-25/250A LCDS 06 LAUSD $10/100% LAUSD $10/100% COBRA PBHI FOCUS CM 20 SV 10/100% LARISA 06 KEC 1 LA PLUS GR07 SVA 20/250A LOWES 07 151 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit LBJ LBK LBL LBM LBN LBU LBX LBY LBZ LC1 LCD LCE LCF LCH LCK LCL LCM LCR LCT LCZ LD1 LD2 LD3 LD4 LD5 LD6 LD7 LDA LDB LDJ LDU LE8 LEA LED LEF LEG LEH LEJ LEP LET LEV LEX LEZ LF1 LFA LFB LFJ LFT LFZ LG2 Plan / Benefit Description SV 10/100% LARISA 06 AB SV PUB SECTOR $10/100% SV PUB SECTOR $15/100% SV PUB SECTOR $20/100% SV PUB SECTOR $10/100% SV 5/100% LBUSD 06 SV 5/100% LBUSD 06 AB SV 5/100% LBUSD 06 CB SV 10/100% LARISA 06 CB LACERS $5 GRP RET LIMITED COVERAGE-TOT. DIS. L.A. CLSC ENHNCD W/EPO DDS SV 10/100% LCKMARTIN 07 L.A. CLSC ENHNCD W/HI DDS $20/100% L.A. CLSC ENHNCD W/OP DDS LOS ANGELES CLSC ENHANCED LACERA-GRP RETIREE $5 SPT 10-25/250A LCDS 06 CB $20/100% COBRA SV $20-$40/500D SV $20-$40/500D CB SV $20-$40/500D CAL CB SV $20-$40/500D FED CB DIS SV $20-$40/500D FED CB EXT SV $20-$40/500D CAL CB EXT SV $20-$40/500D CAL CB DIS EL DORADO STANDARD PLAN SH ELDORADO PART B ONLY SV $20-$40/500D AB SV $20-$40/500D USERRA LIFELINK-EE ONLY COVERAGE SV 20-30/500A LOWE 06 L.A. ENHNCED VALUE W/OPDDS SV 10/100% LCKMARTIN 07 CB SVA 20/250A LOWES 07 CB L.A. ENHNCED VALU W/HI DDS SV 20-30/500A LOWE AB L.A. ENHNCD VALU W/EPO DDS SV 15/100% L3ETI 05 L.ANGLES ENHANCED VALUE SV 20-30/500A LOWE 06 AB SV 20-30/500A LOWE 06 CB LIFE COVERAGE PLAN SV 5/100% LBUSD 06 SVA 20-30/100A LM 07 SV 5/100% LBUSD 06 AB SPT 10-25/250A LCDS 06 AB SV 5/100% LBUSD 06 CB LOS ANGELES II STD PLAN 152 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit LG4 LG5 LG6 LG7 LG8 LGA LGB LGC LGG LGH LHA LHB LHC LHE LHF LHH LHJ LI4 LIC LID LIE LIH LIJ LIR LIT LJA LJB LJD LJE LJF LJG LJH LJJ LJL LJN LK1 LK2 LK3 LK4 LK5 LK6 LK7 LKA LKB LKD LKG LKH LKI LKJ LKK Plan / Benefit Description LOS ANGELES II PLUS PLAN LOS ANGLES II STD W/OP DDS LOS ANGLES II STD W/HI DDS L.A. II PLUS PLAN W/OP DDS L.A. II PLUS PLAN W/HI DDS SV 25/250A LODI 07 SV 25/250A LODI 07 CB SV 25/250A LODI 07 AB SVA 20/250A LOWES 07 AB ORANGE CLASSIC I W/HI DDS SP 10/100% LARISA 06 SP 10/100% LARISA 06 SP 10/100% LARISA 06 CB SP 10/100% LARISA 06 CB SP 10/100% LARISA 06 AB SP 10/100% LARISA 06 AB SV 10/100% LOCKHEED AB LIFELINK - INDEMNITY LOW INC. CHIRO/ACU/MASSAGE LOW INCOME DENTAL LOW INCOME EDUCATION SECURE GLD HEARNG EXAM+AID SV 10/100 LOCKHEED AB LOW INCOME EDUC 12 SESSION LOW INC SH CA TRANSPORTATN SV 15/100A LHMRTN 08 SV 20-30/100A LHMRTN 07 MCC SANTA CLARA DELUX SH07 SV 20-30/100A LHMRTN 07 CB SV 10/100% LCKMARTIN 07 AB SV 20-30/100A LHMRTN 07 AB MCC SANTA CLARA HIGH SH07 SV 20/100 LOCKHEED AB MCC SANTA CLARA LOW SH07 MC COMP SANTA CLARA SH07 HMO 20 PLAN HMO 20 PLAN CBRA HMO 20 PLAN CAL CBRA HMO 20 FED CBR DISABLE HMO 20 FED CBR EXTEND HMO 20 CAL CBR EXTEND HMO 20 CAL CBR DISABLE SV 15/100A LHMRTN 08 CB SVA 20-30/100A LM 07 CB KEC 1 LA DELUXE GR07 SV 10/100% LOCKHEED SV 10/100% LOCKHEED CB SV 10/100 LOCKHEED SV PUB SECTOR $10/100% AB SV 10/100 LOCKHEED CB 153 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit LKL LKM LKN LKO LKU LKZ LL1 LL2 LL3 LL9 LLA LLB LLC LLD LLE LLF LLG LLH LLI LLJ LLL LLP LLQ LLS LLZ LM1 LM2 LMA LMC LMD LME LMF LMH LMJ LMS LMZ LNB LNC LNF LNJ LNZ LO2 LO3 LO4 LOF LOJ LOK LOL LP1 LP2 Plan / Benefit Description SV 20/100 LOCKHEED SV 20/100 LOCKHEED CB SVA 20/100% LOCKHEED SVA 20/100% LOCKHEED CB HMO 20 PLAN USERRA SV PUB SECTOR $10/100% CB LIFE LINK LIFELINK-MENTAL HLTH. ONLY LIFELINK CHEM & PSYCH PBHI GENERIC-REFER TO PBHI SV 0/100% LAMTF 06 SV 10/100% LARISA 06 SV 0/100% LAMTF 06 CB SV 10/100% LARISA 06 CB SV 10/100% LARISA 06 AB LIFELINK/COOKSON/POLYCLAD SV 0/100% LAMTF 06 AB LIFELINK - HIPC PREFERRED LIFELINK - HIPC STANDARD SV PUB SECTOR $15/100% AB 15/100% LACERS GR07 15/250A LLNS GR08 15 LACERS NON-AARP GR08 15/250A LLNS AARP GR08 SV PUB SECTOR $15/100% CB LIBERTY MUTAL SO LIBERTY MUTAL SO COBRA SV 15/100A LHMRTN 08 AB LOCKHEED-MARTIN CUSTOM L.ANGELES MEDICAL W/OP DDS L.ANGELES MED W/EPO DDS SV 15/250A LLNS 07 L.ANGLES MEDICAL W/HI DDS SV PUB SECTOR $20/100% AB LOS ANGELES MEDICAL SV PUB SECTOR $20/100% CB SV PUB SECTOR $10/100% CB NASSCO BASE PLAN SV 15/250A LLNS 07 CB SV PUB SECTOR $10/100% AB NASSCO BASE PLAN COBRA STANDARD $10-$20/80 STANDARD $15-$30/80 STANDARD $20-$40/$250A SV 15/250A LLNS 07 AB STANDARD $15-$30/80 AB 20-30/250A LOKHEED GR07 20-30 LOKHEED NON-AARP GR8 PITNEY BOWES $20/$250 PITNEY BOWES $20/$250 CBRA 154 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit LPJ LPM LQ3 LQ5 LQ9 LQA LQD LQE LQH LQL LQN LQO LR2 LRA LRB LRC LRD LRE LRH LRJ LRZ LSA LSB LSC LSD LSE LSJ LSP LSZ LTA LTB LTD LTE LTF LTH LTJ LTM LTN LUD LUJ LUS LVB LVC LVE LW1 LW3 LWC LWE LWJ LWZ Plan / Benefit Description SVA 20/100% LOCKHEED AB SAN LUIS OBISPO MEDICAL MCC ESS LA LO-PL SH07 MCC ESS LA HI-PL SH07 MCC ESS LA PLUS SH07 SV 10/100% 1500D LODI07 MCC ESS LA DELUXE SH07 SVA 20-40/250A LHMTN 08 CB MCC ESS LA HIGH SH07 MCC ESS LA LOW SH07 MC COMP ESS LA SH07 MCC ESS LA PL-DLXE SH07 PLACER II STANDARD PLAN SV 10/100% 1500D LODI07 CB SV 10/100% LAUSD 06 SANTA CLARA CLASSIC I S CLARA CLSC I W/OP DDS S CLARA CLSC I W/EPO DDS S CLARA CLSC I W/HI OP DDS SV 10/100% LAUSD 06 AB SV 10/100% LAUSD 06 CB SV 10/100% 1500D LODI07 AB SV 10/100% CSB 05 SV 10/100% CSB 05 CB KEC 1 LA PL-DLXE GR07 S.L. OBSPO MEDICL W/EPODDS SV 10/100% CSB 05 AB S.L. OBSPO MEDICL W/ODPDDS LAUSD $5 GRP RET COBRA LABOR & TRUST ADMIN SV 10/100% LOCKHEED 07 RESERVED FOR PPO LIFE SV 20/250A LOWES 07 SV 10/100% LOCKHEED 07 CB SV 10/100% LOCKHEED 07 AB SV 15/100% L3ETI 05 AB RESERVED FOR LIFETIME MAX RETEST FOR CDHP SV 10/100 LAUSD SV 10/100 LAUSD AB SV 10/100 LAUSD CB SVA 20-30/100A LM 07 AB KEENAN COMP 1 LA GR07 SV 20/250A LOWES 07 CB SP 10/100% L3/CS SV 20-30/500A LOWE CB KEC 1 LA LOW GR07 SV 20-30/500A LOWE SP 10/100% L3/CS AB SP 10/100% L3/CS CB 155 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit LX3 LX5 LX9 LXA LXB LXC LXD LXE LXF LXH LXJ LXL LXM LXN LXO LXW LXZ LY3 LY5 LY9 LYA LYB LYC LYD LYE LYF LYH LYJ LYL LYM LYN LYO LYW LYZ LZ3 LZ5 LZ7 LZ9 LZA LZB LZC LZD LZE LZF LZH LZJ LZL LZM LZN LZO Plan / Benefit Description MCC 2 LA LO-PL SH07 MCC 2 LA HI-PL SH07 MCC 2 LA PLUS SH07 SV 25/100A LA MACH 06 SV 5/100% LARISA 06 KEC 1 LA LO-PL GR07 MCC 2 LA DELUXE SH07 SVA 20-40/250A LHMTN 08 AB SV 10-20/100DSEL LAR 06 MCC 2 LA HIGH SH07 SV 25/100A LA MACH 06 AB MCC 2 LA LOW SH07 SV 15/100% LARISA 06 MC COMP 2 LA SH07 MCC 2 LA PL-DLXE SH07 SV 20-40/250A LHMRTN 08 SV 25/100A LA MACH 06 CB MCC 1 LA LO-PL SH07 MCC 1 LA HI-PL SH07 MCC 1 LA PLUS SH07 SV 3/100% LA MACH 06 SV 5/100% LARISA 06 CB KEC 1 LA HIGH GR07 MCC 1 LA DELUXE SH07 SV 20/250A LOWES 07 AB SV 10-20/100DSEL LAR 06 CB MCC 1 LA HIGH SH07 SV 3/100% LA MACH 06 AB MCC 1 LA LOW SH07 SV 15/100% LARISA 06 CB MC COMP 1 LA SH07 MCC 1 LA PL-DLXE SH07 SV 20-40/250A LHMRTN 08 CB SV 3/100% LA MACH 06 CB MCC 3 LA LO-PL SH07 MCC 3 LA HI-PL SH07 SH 5/100% LACERA GR06 MCC 3 LA PLUS SH07 SV 15/100A LA MACH 06 SV 5/100% LARISA 06 AB KEC 1 LA HI-PL GR07 MCC 3 LA DELUXE SH07 SVA 20-40/250A LHMTN 08 SV 10-20/100DSEL LAR 06 AB MCC 3 LA HIGH SH07 SV 15/100A LA MACH 06 AB MCC 3 LA LOW SH07 SV 15/100% LARISA 06 AB MC COMP 3 LA SH07 MCC 3 LA PL-DLXE SH07 156 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit LZW LZZ M01 M02 M03 M04 M05 M06 M11 M12 M13 M14 M15 M16 M17 M1D M1J M1R M1Z M2J M2Z M3J M3X M3Z M4G M4J M4T M5G M6J MAA MAB MAC MAF MAG MAH MAJ MAM MAR MAX MB2 MB3 MBB MBC MBF MBJ MC0 MC1 MC2 MC3 MC5 Plan / Benefit Description SV 20-40/250A LHMRTN 08 AB SV 15/100A LA MACH 06 CB MEDICAL-PUBLIC ASST-FAMILY MEDICAL-MED NEED FAM MEDICAL-MED IND CHILD MEDICAL-PUBLIC ASST AGED MEDICAL-PUB ASST DISABLED MEDICAL-PUBLIC ASST BLIND MEDICAID/CALOP-FAMILY MEDICAID/CALOP-CHILD MEDICAID/CALOP-ADULT MEDICAID/CALOP-AGED LIFELINK CRISIS MH MEDICAID/CALOP-LTC MEDICAID/CALOP-BLND/DISABL MADERA STANDARD PLAN SELECT HOSP $10/$100 AB MARIN STANDARD PLAN SELECT HOSP $10/$100 CBRA SELECT HOSP $15/$250 AB SELECT HOSP $15/$250 COBRA SV 15/250A MABC 05 AB AB1401 SELECT HOSP 20/400 SELECT HOSP $20/400 CBRA SV 20/100% 06 SV 20/100% 06 AB 10/5V 1YR MSG THRPY GR07 SV 20/100% 06 CB $25-$30/$500A AB MARIN CNTY STNRD PLAN MARIN STNDRD PART B ONLY SV 15-25/100A MARTT 06 SV 20/100% 07 SV 20/100% 07 CB SV 20/100% 07 AB SV $15/100% ST MARY MED AB SV 15-25/100A MARTT 06 CB SVA 15-25/100A MARRIOTT SV 15-25/100A MARTT 06 AB SP 10/100 MORLEY BUILD CB SV 15/250A MABC 05 CB SP 10/100 MORLEY BUILDER SV 15/250A MABC 05 SV 15-25/100A MARTT 07 SP 10/100 MORLEY BUILD AB RX $0 CO-PAY MANAGED CL RX STAND. 10 ALLERGY SER.PLAN MARRIOTT $15/$100 MARRIOTT $15/$100 COBRA SV 15-25/100A MARRIOTT 157 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit MC6 MC7 MCA MCF MCJ MCM MCP MCS MD1 MD2 MD3 MD4 MD5 MD6 MD7 MD8 MDA MDB MDC MDD MDF MDG MDJ MDK ME1 ME2 ME3 ME4 ME5 ME6 ME7 ME8 MEA MEB MED MEJ MEK MEP MER MET MEV MF1 MF2 MF3 MF4 MF5 MF6 MF7 MF8 MF9 Plan / Benefit Description $25-$30/$500A $25-$30/$500A COBRA SV SELECT 10-20/100D 07 SV 5/100% MILLS PEN 07 MARRIOTT $15/$100 AB MADERA CLASSIC I MEDICARE COST PLUS PLAN MEDICARE COST STANDARD PLN SH MADERA STD MED SH MADERA STD W/ HI DEN SH MADERA PART B STD MED SH MADERA PART B W/ HI DEN SH MADERA PLUS MED SH MADERA PLUS W/ HI DEN SH MADERA PART B PLUS MED MADERA PT B PLUS W/ HI DEN SV 20-30/90% MCKES 06 SV 10/100% MSD 08 MCDONNELL-DOUGLAS CSTM RET SV 20-30/90% MCKES 06 CB SV 15-25/100A MARTT 07 CB SV 20-30/200D MODEST 07 SV 20-30/90% MCKES 06 AB SV 25-50/50% MODTECH 08 SH MERCED STD MED SH MERCED STD W/ HI DEN SH MARIN PART B STD MED SH MERCED PART B W/ HI DEN SH MERCED PLUS MED MERCED PLUS MED W/ HI DEN SH MERCED PART B PLUS MED SH MERCED B PLUS W/ HI DEN SV SELECT 10-20/100D 07 CB SV 10/100% MSD 08 CB SV $15/100% ST MARY MED CB SV SELECT 10-20/100D AB SV 25-50/50% MODTECH 08 CB MADERA CLASSIC I W/EPO DDS SV 15/250A MERCK 07 SV 15/250A MERCK 07 CB SV 15/250A MERCK 07 AB RX $1 CO-PAY MANAGED CL RX RX $2 CO-PAY MANAGED RX RX $3 CO-PAY MANAGED CL RX RX $4 CO-PAY MANAGED CL RX RX $5 CO-PAY MANAGED CL RX RX $6 CO-PAY MANAGED CL RX RX $7 CO-PAY MANAGED CL RX RX $8 CO-PAY MANAGED CL RX RX $9 CO-PAY MANAGED CL RX 158 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit MFA MFB MFC MFD MFG MFK MFX MGA MGB MGJ MH0 MH1 MH2 MH8 MHA MHC MHD MHJ MHS MHX MHZ MI2 MIJ MJA MJB MJR MKA MKB MKF MKH MKL MKW ML2 MLB MLC MLF MLJ MM2 MM3 MMA MMB MMC MMG MMH MML MMN MMO MMU MMY MN6 Plan / Benefit Description SV SELECT 10-20/100D 07 AB SV 15/250A MERLE NOR 07 SV 15/250A MERLE NOR 07 CB SV 15/250A MERLE NOR 07 AB SV 20-30/200D MODEST 07 CB SV 25-50/50% MODTECH 08 AB RX $10 CO-PAY MANAGD CL RX SV SELECT 20-40/400D 07 SV 10/100% MSD 08 AB SV SELECT 20-40/400D AB LIFELINK MH100 1995 LIFELINK-MENTAL HEALTH 100 LIFELINK MH80 1995 LIFELINK-MENTAL HEALTH 80% SV 15-25/240A MHS 06 SV 15-25/240A MHS 06 CB 2-DEDUC MH06 SV MEMORIAL 15-25/240A AB SV MEMORIAL 15-25/240A SV 15-25/240A MHS 06 AB SV MEMORIAL 15-25/240A CB SV 15-25/100A MARRIOTT CB SV 15-25/100A MARRIOTT AB SV SELECT 20-40/400D 07 CB SV SELECT 15-30/250D 07 SVA 15-25/100A MARRIOTT CB SV SELECT 20-40/400D 07 AB SV SELECT 15-30/250D 07 CB SV 15-25/100A MARTT 07 AB ARP MCC S MATEO HI SH08 ARP MCC S MATEO LO SH08 ARP MCC S MATEO SH08 SV 20/250A MERRILL CB SV SELECT 15-30/250D 07 AB SV 20/250A MERRILL SV 5/100% MILLS PEN 07 CB SV 20/250A MERRILL AB 2003 SMI ONLY HMO 10 2003 SMI ONLY HMO 15/20 SMI+SUPP A (MULTI TIER) SMI + SUPPLEMENTAL SP 10/100% MOSSY 06 SV 15/250A MGM 08 SP 10/100% MOSSY 06 CB SP 10/100% MOSSY 06 AB SMI+NATL UB SUPP (M TIER) 2002 SMI ONLY (MUL TIER) SMI + SUPP U (MULTI TIER) 2002 SMI PLAN U PLUS MULTI MCC 1 MADERA PP-PL SH07 159 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit MN7 MN9 MNA MNE MNG MNJ MNN MNP MNZ MOA MOB MPA MPB MPC MPD MPE MPG MPH MPI MPK MPL MPM MPN MPO MPP MPQ MPR MPS MPT MPU MPV MPW MPX MPY MPZ MR1 MR2 MR3 MR4 MR5 MR6 MR7 MR8 MRJ MRY MS1 MSA MSC MSD MT1 Plan / Benefit Description MCC 1 MADERA EP-PL SH07 MCC 1 MADERA PLUS SH07 SV 15/250A MERLE NOR 06 MCC 1 MADERA EP SH07 SV 15/250A MGM 08 CB SV 15/250A MERLE NOR 06 AB MC COMP 1 MADERA SH07 MCC 1 MADERA PP SH07 SV 15/250A MERLE NOR 06 CB MONTEREY BASIC PLAN MONTEREY PART B ONLY SMI + SUPPLEMENT A SMI + SUPPLEMENT B SMI+CUSTOM HMO SUPPLEMENT MED. COST PLUS UNDER 65 SMI ONLY 05 SV 15/250A MGM 08 AB SMI+PACADVANTAGE PREF/PLUS SMI + PACADVANTAGE STD SMI CARVE OUT RIALTO BH05 SMI + SUPPLEMENT L SMI + SUPPLEMENT M SMI + NAT'L UB SUPPLEMENT SMI ONLY SMI ONLY - PPO/INDEMNITY SUTTER LOW OPT MH/CD/SMI CUSTOM POS PBH RETAIL SMI+CUSTOM POS SUPPLEMENT SUTTER SMI + SUPPLEMENT U MENTAL HEALTH CARVE OUT SMI CARVE OUT 3 CUSTOM HMO PBH RETAIL SMI PLAN U PLUS SMI CARVE OUT 4 SH MARIN STD MED SH MARIN STD MED W/ HI DEN SH MARIN PART B STD MED SH MARIN PART B W/ HI DEN SH MARIN PLUS MED SH MARIN PLUS MED W/ HI DE SH MARIN PART B PLUS MED MARIN PT B PLUS W/ HI DEN SVA 15-25/100A MARRIOTT AB SV $15/100% ST MARY MED STANDARD 5 PLAN SANTA CRUZ PART B ONLY SANTA CRUZ BASIC PLAN MED COST STAND. UNDER 65 SELECT HOSP $10/$100 160 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit MT2 MT3 MTA MTB MTC MTD MTE MTF MTG MTH MTJ MTK MTM MU6 MU7 MU9 MUE MUN MUP MVA MVJ MVZ MWF MWG MWI MWP MWQ MWU MWV MWW MWY MYB MYD MYG MYI MYQ MYU MYV MYW MYY N01 N02 N03 N04 N05 N06 N07 N08 N09 N0J Plan / Benefit Description SELECT HOSP $15/$250 SELECT HOSP $20/$400 SH BASIC PLAN SAN MATEO SH SAN MATEO CO. B ONLY SV SELECT 15-30/250D SV SELECT 15-30/250D CB SV SELECT 10-20/100D SV SELECT 10-20/100D CB SV SELECT 20-40/400D SV SELECT 20-40/400D CB SV SELECT 15-30/250D AB 10/5V 1YR MSG THRPY SH07 10/5V 1YR MSG THRPY SH08 MCC 3 MADERA PP-PL SH07 MCC 3 MADERA EP-PL SH07 MCC 3 MADERA PLUS SH07 MCC 3 MADERA EP SH07 MC COMP 3 MADERA SH07 MCC 3 MADERA PP SH07 SV 20/100% MRYVALE 06 SV 20/100% MRYVALE 06 AB SV 20/100% MRYVALE 06 CB SV 5/100% MILLS PEN 07 AB SV 20-30/200D MODEST 07 AB ARP MCC 1 MADRA EP-PL SH08 MADERA CLASSIC I W/ODP ARP MCC 1 MADRA PP-PL SH08 ARP MCC 1 MADRA PP SH08 ARP MCC 1 MADRA PLUS SH08 ARP MCC 1 MADRA SH08 ARP MCC 1 MADRA EP SH08 SV 20/250A MOTOROLA 07 SV 20/250A MOTOROLA 07 CB SV 20/250A MOTOROLA 07 AB ARP MCC 3 MADRA EP-PL SH08 ARP MCC 3 MADRA PP-PL SH08 ARP MCC 3 MADRA PP SH08 ARP MCC 3 MADRA PLUS SH08 ARP MCC 3 MADRA SH08 ARP MCC 3 MADRA EP SH08 INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS SV 10-20/100A NAT'L 06 AB 161 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N1J N1N N1Z N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N2J N2N N2Z N30 N3J N3N N3Z N42 N47 N48 N4J N4N N4U N4Z N52 N57 N58 N5J N5N N5U N5Z N62 N67 N68 N6J N6N N7J Plan / Benefit Description INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS 2002 UB PLAN 1 AB SV 5/100% NAT'L 06 CB 2002 UB PLAN 1 COBRA INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLAN INDEMNITY PLAN INDEMNITY PLAN INDEMNITY PLANS INDEMNITY PLANS 2002 UB PLAN 2 AB SV 10/100% NAT'L 06 CB 2002 UB PLAN 2 COBRA INDEMNITY PLANS 2002 UB PLAN 3 AB SV 15/100% NAT'L 06 CB 2002 UB PLAN 3 COBRA KEC NEVADA CG GR07 KEC NEVADA EP CG GR07 KEC NEVADA PP CG GR07 SV NAT'L $10/$20/$100A AB SV 10-20/100A NAT'L 06 CB 0/12-1W NON-ER TRANS GR07 2002 UB PLAN 4 COBRA KEC NEVADA CGII GR07 KEC NEVADA EP CGII GR07 KEC NEVADA PP CGII GR07 SV NATL $15-$30/250A AB SV 15-30/250A NAT'L 06 CB 0/30-1W NON-ER TRANS GR07 2002 UB PLAN 5 COBRA KEC NEVADA CGEH GR07 KEC NEVADA EP CGEH GR07 KEC NEVADA PP CGEH GR07 SV NAT'L $15/$30/$400A AB SV 15-30/400A NAT'L 06 CB SV NATL $20-$40/$250D AB 162 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit N7N N8J N8N N9J N9N NA0 NA1 NA2 NA3 NA4 NA5 NA6 NA7 NA8 NA9 NAA NAB NAC NAD NAE NAF NAG NAH NAI NAJ NAK NAL NAM NAN NAP NAQ NAR NAS NB2 NB3 NBJ NC3 NCA NCB NCC NCE NCF NCJ NCL NCP NCS NDJ NDL NDP NEJ Plan / Benefit Description SV 20-40/250D NAT'L 06 CB SV NATL $20-$40/$400D AB SV 10/250A NAT'L 06 CB SV 15/250A NAT'L 06 AB SV 15/250A NAT'L 06 CB NAT'L $20/$250 100% COBRA PHS NATL $5/100% CBRA PHS NATL $10/100% CBRA PHS NATL $10/$100/100%CBRA PHS NATL $10/$250/100%CBRA PHS NATL $15/$250/100%CBRA PHS NATL $15/100% CBRA NATL HMO $15OV 100% COBRA NATL STD$15/$100/100% CBRA NAT'L $20/$250 100% PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100/100% PHS NATL $10/$250/100% PHS NATL $15/$250/100% PHS NATL $15/100% NATL POS $10OV 100%/70% NATL POS $10OV 90%/70% NATL STD $15/$100/100% NATL POS $10OV $250/60% NATL POS $15OV 80%/60% NATL POS $15OV $150/70% NATL HMO $15OV 100% PHS NATL $20/$500 PHS NATL $20/$500 COBRA NAT'L HMO $10OV 100% S CAL GAS NAT'L HMO $10 SEMPRAS NAT'L HMO $5 $10/100% PLAN $10/100% PLAN COBRA SV NATL $10/100% FRITOLAY NATL $15/100% CBR SH-SACRAMENTO COUNTY SACTO COUNTY-PART B FRITO LAY NAT'L $15/100% NEVADA CLASSIC I W/EPO DDS SV 20-40/250A NATION 07 SV NATL $15/100% AB KEENAN COMP NEVADA GR07 NEVADA CLASSIC I W/ODP NEVADA CLASSIC I SV NATL $10/$100A AB KEC NEVADA EP GR07 NORTHERN DENTAL PLAN SV NATL $10/$250A AB 163 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit NEL NF4 NF5 NF6 NF7 NF8 NFD NFE NFF NFG NFH NFJ NFM NG1 NG2 NG3 NG4 NG5 NG6 NG7 NGA NGC NGE NGF NGG NGJ NGN NGP NGZ NH NHA NHB NHC NHE NHF NHJ NHU NHW NHY NHZ NIG NIJ NJJ NJZ NKJ NKZ NL8 NLG NLH NLJ Plan / Benefit Description KEC NEVADA PP GR07 SV NAT'L $10/$20/$100A CB SV NATL $15-$30/250A CB SV NAT'L $15/$30/$400A CB SV NATL $20-$40/$250D CB SV NATL $20-$40/$400D CB SV NAT'L $10/$20/$100A SV NATL $15-$30/250A SV NAT'L $15/$30/$400A SV NATL $20-$40/$250D SV NATL $20-$40/$400D SV NATL $15/$250A AB SV 15-30/400A NATL 07 NAT'L PLAN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT PLAN 2A $10 GRP RET NAT PLAN 2B $10 GRP RET NAT PLAN 3A $15 GRP RET NAT PLAN 3B $15 GRP RET NAT'L PLN 2C $20 GRP RET NAT'L PLN 2D $20 GRP RET MCC NEVADA EP SH07 SVA 15-30/300A 07 SV 15-30/300A 07 SV NATL $15/$100A AB MC COMP NEVADA SH07 MCC NEVADA PP SH07 NATL POS $10OV 100%/70% CB NOT USED SVA 20-40/400A 07 SVA 20-40/400A 07 CB SVA 20-40/400A 07 AB SV 40-50/80% NORTH 06 SV 20-40/250A NATION 07 CB PHS NATL $20/$500 AB ARP MCC NEVDA PP SH08 ARP MCC NEVDA SH08 ARP MCC NEVDA EP SH08 NATL POS $10OV 90%/70% CB SV 15-30/300A 07 CB SV 10/100% NAT'L 06 AB SV 5/100% NAT'L 06 AB NATL POS $10OV $250/60% CB SV 10/250A NAT'L 06 AB NATL POS $15OV 80%/60% CB 24HR NURSLINE WL-SH/GR08 24HOUR NURSE LINE SH07 SV 20-40/250A+10% NI 08 SV 15/100A NAT'L 06 AB 164 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit NLZ NM1 NM2 NM3 NM4 NM5 NME NMF NMG NMP NMS NN1 NN2 NN3 NN4 NN5 NN6 NN7 NNA NNB NNC NND NNE NNF NNG NNJ NNK NNL NNM NNN NNP NNQ NNR NNS NNT NNU NNV NNX NNY NO1 NOJ NP1 NP2 NP3 NP4 NP5 NP6 NP7 NP8 NPA Plan / Benefit Description NATL POS $15OV $150/70% CB 2002 UB PLAN 1 2002 UB PLAN 2 2002 UB PLAN 3 2002 UB PLAN 4 2002 UB PLAN 5 NEVADA MEDICAL W/EPO DDS SVA 15-30/300A 07 CB SVA 15-30/300A 07 AB NEVADA MEDICAL W/PPO DDS NEVADA MEDICAL SV NATL $5/100% CB SV NATL $10/100% CB SV NATL $15/100% CB SV NATL $10/$100A CB SV NATL $10/$250A CB SV NATL $15/$250A CB SV NATL $15/$100A CB SV NATL $5/100% SV NATL $10/100% SV NATL $15/100% SV NATL $10/$100A SV NATL $10/$250A SV NATL $15/$250A SV NATL $15/$100A SV NATL $5/100% AB SV 10/250A NAT'L 06 SV 15/100A NAT'L 06 SV 10/100% NAT'L 06 SV 5/100% NAT'L 06 SV 15/250A NAT'L 06 SV 10-20/100A NAT'L 06 SV 10/100% NAT'L 06 SV 15-30/400A NAT'L 06 SV 20-40/250D NAT'L 06 SV 15/100% NAT'L 06 SV 15-30/250A NAT'L 06 SV 15-30/250A NAT'L 06 AB SV 20-40/400D NAT'L 06 NORTHROP PLAN SV 15/100% NAT'L 06 AB SH NAPA STD MED SH NAPA STD MED W/ HI DEN SH NAPA PART B STD MED SH NAPA PART B W/ HI DEN SH NAPA PLUS MED SH NAPA PLUS MED W/ HI DEN SH NAPA PART B PLUS MED NAPA PART B PLUS W/ HI DEN NAPA BASIC PLAN NO DTL 165 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit NPB NPJ NQJ NQN NQZ NR1 NR2 NR3 NR4 NR5 NR6 NR7 NR8 NR9 NRA NRB NRC NRJ NRZ NS2 NS3 NSA NSB NSJ NSL NSS NSZ NT8 NTB NTC NTE NTG NTH NTJ NTL NTM NTN NTP NTQ NTR NUJ NVA NVC NVE NVF NVJ NWA NWC NWE NWF Plan / Benefit Description NAPA/SONOMA PART B ONLY PHS NATL $5/100% AB PHS NATL $10/100% AB SV 10/100% NAT'L 06 CB NAT'L HMO $10OV 100% COBRA $10G/$20B $10G/$20B/$30NF $10G/$25B/$40NF $10G/$25B/$50NF $10G/$25B $10G/$35B $15G/$25B $15G/$35B $15G/$25B/$40NF $5G/$10B $5G/$15B $10G/$35B PHS NATL $10/$100/100% AB S CAL GAS NAT'L HMO $10 CB $3G/$3B $15-$25/$240A NAPA,SOLANO,SONOMA PRT B SOLANO, SONOMA PRT B ONLY PHS NATL $10/$250/100% AB CREATED IN ERROR/CAN REUSE SOLANO,SONOMA BASIC PLAN SEMPRA NAT'L HMO $5 COBRA 0/24-1W NON-ER TRANS GR08 0/24-1W NON-ER TRANS SH07 0/24-1W NON-ER TRANS SH07 MCC ESS NEVADA EP SH07 SV 15-30/300A 07 AB SV 20-40/250A+10% NI 08 CB PHS NATL $15/$250/100% AB 0/24-1W NON-ER TRANS SH08 MC COMP ESS NEVADA SH07 SV 15/100A NAT'L 06 CB MCC ESS NEVADA PP SH07 0/24-1W NON-ER TRANS SH08 0/24-1W NON-ER TRANS GR07 PHS NATL $15/100% AB SVA 15-30/300A WB 06 SVA 15-30/300A WB 06 CB SV 40-50/80% NORTH 06 CB SVA 15-30/300A WB 06 AB SV 15-30/400A NAT'L 06 AB SVA 20-40/400A WB 06 SVA 20-40/400A WB 06 CB SV 20-40/400A 07 SVA 20-40/400A WB 06 AB 166 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit NWH NWJ NWK NXJ NYJ NYN NZ1 NZ3 NZE NZF NZH NZJ O01 O02 O03 O04 O05 O06 O07 O08 O09 O10 O11 O12 O13 O14 O15 O16 O17 O18 O19 O1C O1P O1Q O1R O1W O1Y O20 O21 O22 O23 O24 O25 O26 O27 O28 O29 O2G O2N O2Q Plan / Benefit Description SV 20-40/400A 07 CB NATL STD $15/$100/100% AB SV 20-40/400A 07 AB SV 10/100% NAT'L 06 AB SV 20-40/250D NAT'L 06 AB SV 20-40/400D NAT'L 06 CB NORTHROP PLAN (COBRA) $15-$25/$240A COBRA SV 40-50/80% NORTH 06 AB SV 20-40/250A NATION 07 AB SV 20-40/250A+10% NI 08 AB $15-$25/$240A AB 100/70 $5 OV/$250 DED OON 100/70 $5 OV/$500 DED OON 100/70 $10 OV/$250 DED OON 100/70 $10 OV/$500 DED OON 100/70 $15 OV/$250 DED OON 100/70 $15 OV/$500 DED OON 90/70 $5 OV/$250 DED OON 90/70 $5 OV/$500 DED OON 90/70 $10 OV/$250 DED OON 90/70 $10 OV/$500 DED OON 90/70 $15 OV/$250 DED OON 90/70 $15 OV/$500 DED OON 100/90/70 $5/$10 $250 DED 100/90/70 $5/$10 $500 DED 100/90/70 $5/$15 $250 DED 100/90/70 $5/$15 $500 DED 100/90/70 $5/$20 $250 DED 100/90/70 $5/$20 $500 DED 100/90/70 $10/$15 $250 DED ORANGE STANDARD PLAN STANDARD 90%/$5 - POS 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 STANDARD 90%/$5-POS COBRA 100/90/70 $10/$15 $500 DED 100/90/70 $10/$20 $250 DED 100/90/70 $10/$20 $500 DED 100/80/70 $5/$10 $250 DED 100/80/70 $5/$10 $500 DED 100/80/70 $5/$15 $250 DED 100/80/70 $5/$15 $500 DED 100/80/70 $5/$20 $250 DED 100/80/70 $5/$20 $500 DED 100/80/70 $10/$15 $250 DED NAT'L PLN 2 $10 GRP RET NAT'L PLN 2 $10 GRP RET 10-20/750A T2A GR07 167 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit O2R O2W O30 O31 O32 O33 O34 O35 O36 O37 O38 O39 O3C O3Q O3R O3W O40 O41 O42 O43 O44 O45 O46 O47 O48 O49 O4C O4G O4H O4Q O4R O4W O50 O51 O52 O53 O54 O55 O56 O57 O58 O59 O5C O5N O5Q O5R O5W O60 O61 O62 Plan / Benefit Description 15-25/200D T3A GR07 10-15/50A T1A GR07 100/80/70 $10/$15 $500 DED 100/80/70 $10/$20 $250 DED 100/80/70 $10/$20 $500 DED 100/80/60 $5/$10 $250 DED 100/80/60 $5/$10 $500 DED 100/80/60 $5/$15 $250 DED 100/80/60 $5/$15 $500 DED 100/80/60 $5/$20 $250 DED 100/80/60 $5/$20 $500 DED 100/80/60 $10/$15 $250 DED ORANGE PLUS PLAN 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 100/80/60 $10/$15 $500 DED 100/80/60 $10/$20 $250 DED 100/80/60 $10/$20 $500 DED 90/80/70 $5/$10 $250 DED 90/80/70 $5/$10 $500 DED 90/80/70 $5/$15 $250 DED 90/80/70 $5/$15 $500 DED 90/80/70 $5/$20 $250 DED 90/80/70 $5/$20 $500 DED 90/80/70 $10/$15 $250 DED ORANGE STANDARD W/OPT DENT NAT PLAN 2A $10 GRP RET BOEING HOURLY $15 GRP RET 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 90/80/70 $10/$15 $500 DED 90/80/70 $10/$15 $250 DED 90/80/70 $10/$20 $500 DED 90/80/60 $5/$10 $250 DED 90/80/60 $5/$10 $500 DED 90/80/60 $5/$15 $250 DED 90/80/60 $5/$15 $500 DED 90/80/60 $5/$20 $250 DED 90/80/60 $5/$20 $500 DED 90/80/60 $10/$15 $250 DED ORANGE STANDARD W/HI DENTL NAT PLAN 2B $10 GRP RET 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 90/80/60 $10/$15 $500 DED 90/80/60 $10/$20 $250 DED 90/80/60 $10/$20 $500 DED 168 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit O63 O64 O65 O66 O67 O68 O69 O6C O6G O6N O6Q O6R O6W O70 O7C O7G O7Q O7R O7W O88 O8G O8Q O8R O8W O9E O9G O9H O9Q O9R O9W OA4 OAA OAB OAN OAS OB2 OB4 OB8 OBL OC1 OC2 OC3 OC4 OC5 OC6 OC7 OC8 OCE OCQ OD4 Plan / Benefit Description 100/90/70 $10/10%/30% 250D 100/90/70 $10/10%/30% 250D 100/80/60 $10/20%/40% 250D 100/80/60 $10/20%/40% 250D 100/80/50 $10/$20/50% 500D 100/80/50 $15/$30/50% 500D 100/80/50 10/20/50% 500D ORANGE PLUS PLAN W/OP DENT NAT PLAN 3A $15 GRP RET NAT PLAN 3A $15 GRP RET 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 RESERVED POS OPTION ORANGE PLUS PLAN W/HI DENT NAT PLAN 3B $15 GRP RET 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 STD $10 GRP RETIREE STD $10 GRP RETIREE 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 10/100% AARP GR08 STD $15 GRP RETIREE 10/100% NON-AARP GR08 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GRP RET 20/100% NON-AARP GR08 NAT'L ACCTS EXTENDED OOA LAUSD $5 GRP RETIREE NAT PLAN 2A $10 GR 06 NAT PLAN 2A $10 GR 06 10-20/250A NON-AARP GR08 10 SDCERA NON-AARP GR08 SH ORANGE STD MED SH ORANGE STD MED W/ HI DE SH ORANGE PART B STD MED SH ORANGE PART B W/ HI DEN SH ORANGE PLUS MED SH ORANGE PLUS W/ HI DEN SH ORANGE PART B PLUS MED ORANGE PT B PLUS W/ HI MED END ORANGE BASIC W/ NO DEN $15 IBEW GRP RET NAT'L PLN 2D $20 GR 06 169 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit OD5 OD6 OD8 ODA ODC OE2 OEA OF1 OF2 OF3 OF4 OF5 OF6 OF7 OF8 OF9 OFA OFB OFC OFD OFE OG1 OG2 OG4 OG5 OG6 OG7 OG8 OG9 OGA OGC OGF OGG OGN OGO OGS OGU OGW OGX OGY OGZ OH1 OH2 OH4 OHC OHD OHO OHP OHU OJ2 Plan / Benefit Description 10-15/50A T1A GR07 NAT'L PLN 2D $20 GR 06 15/250A AARP GR08 10/100% NON-AARP GR08 MCDONNELL-DOUGLAS CSTM RET NAT PLAN 2B $10 GR 06 5/100% NON-AARP GR08 RESERVE FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RX RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO NAT'L PLAN 1 $5 GRP RET ORANGE II STANDARD PLAN ORANGE II PLUS PLAN ORANGE II STD W/OPT DDS ORANGE II STD W/HI OP DDS ORANGE II PLS PLN W/OP DDS ORANGE II PLS PLN W/HI DDS STD $15 GRP RETIREE ELK GROVE USD $20 GR NAT'L PLN 2D $20 GRP RET 20-40/250A NON-AARP GR08 NAT'L PLAN 1 $5 GRP RET NAT'L PLAN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET STD $10 GRP RETIREE 5/100% AARP GR08 10-20/250A AARP GR08 15-25/500A AARP GR08 15-25/500A NON-AARP GR08 15/250A AARP GR08 BOEING NA-HRLY $10 GRP RET BOEING NA-HRLY $10 GRP RET BOEING HOURLY $15 GRP RET 0 UFCW NON-AARP GR08 20/100% AARP GR08 BOEING NA-HRLY $10 GRP RET SH PREFERRED UFCW NAT PLAN 3A $15 GR 06 170 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit OJP OK4 OK6 OKD OKG OKM OL1 OL4 OLD OLH OLL OLY OM8 OMA OMH OMJ OMK OML OMM ON2 ON4 ON5 ON6 ON7 ON9 ONA ONC ONG ONJ ONV ONX OO7 OO9 OOF OON OP2 OPB OPC OPG OPJ OQ8 OQA OQP ORB ORC ORI ORX OS2 OS3 OS4 Plan / Benefit Description NAT'L PLAN 1 $5 GRP RET NAT PLAN 3B $15 GR 06 NAT PLAN 3B $15 GR 06 5/100% LAUSD NON-AARP GR08 15 BO HRLY-F NO-AARP GR08 20-40/250A NON-AARP GR08 LACERS $5 GRP RET STD $10 GR 06 5/100% LAUSD NON-AARP GR08 10 BO HRLY NO-AARP GR08 LACERS $5 GRP RET 20/100% NON-AARP GR08 10-20/250A NON-AARP GR08 SH PREFERRED NON-AARP GR08 GENERAL MTRS GRP RET HRLY SV 20-40/250D OC PET 07 20-30/100% GEN MOTRS GR06 SV 20-40/250D OC PET 07 CB SV 20-40/250D OC PET 07 AB NAT'L PLN 2 $10 GRP RET NAT PLAN 2A $10 GRP RET NAT PLAN 2B $10 GRP RET NAT PLAN 3A $15 GRP RET NAT PLAN 3B $15 GRP RET 20/100% PBGH NON-AARP GR08 15/100% IBEW NON-AARP GR08 SH STANDARD $10 NAT'L PLN 2C $20 GRP RET 10-20/250A AARP GR08 5/100% NON-AARP GR08 SH RETIREE STD 10 NAT'L PLN 2C $20 GR 06 10-20/250A NON-AARP GR08 POS OON SB1221 POS - OUT OF AREA PBGH $20 GRP RET PLAN PBGH $20 GRP RET PLAN RX NOT THRU RXSOL $250INJ 20 PBGH NON-AARP GR08 15/250A NON-AARP GR08 10-20/500A NON-AARP GR08 15/250A NON-AARP GR08 5/100% NON-AARP GR08 SH-B ONLY ORANGE COUNTY 15/100% TRIBUNE AARP GR08 $15 100% TRIBUNE GR OTHR RX NOT THRU RX SOL STD $15 GR 06 CITY OF SAN DIEGO GR 2004 STD $15 GR 06 171 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit OS6 OSI OST OSZ OT2 OT4 OT5 OT7 OTH OTK OTZ OU2 OU4 OUF OUJ OUQ OV2 OV4 OV6 OV8 OW2 OW4 OW6 OWC OWP OWU OYA OZG P00 P0J P1C P1D P1E P1F P1G P1J P1L P1R P1S P1W P1Z P2C P2D P2G P2J P2P P2V P2Z P30 P38 Plan / Benefit Description STD $15 GR 06 CITY OF SAN DIEGO GR 06 PUBLIC SECTOR $10 GRP RET LAUSD $5 GRP RET COBRA SACRAMENTO II STD PLAN SACRAMENTO II PLUS PLAN SACRAMENTO II STD W/OP DDS SACTO II PLS PLN W/OP DDS 5/100% AARP GR08 5/100% AARP GR08 20-40/250A AARP GR08 SH PREFERRED GR 06 SH PREFERRED GR 06 UFCW RETIREE $25 25 UFCW NON-AARP GR08 10/100% NON-AARP GR08 SH STANDARD $10 GR 06 SH STANDARD $10 GR 06 SH STANDARD $10 GR 06 10-20/250A AARP GR08 SH RETIREE STD 10 06 SH RETIREE STD 10 06 SH RETIREE STD 10 06 0/100% LADWP NON-AARP GR08 SH RETIREE LADWP CUSTOM 15/250A NON-AARP GR08 10/100% AARP GR08 10/100% NON-AARP GR08 INPATIENT PSYCHIATRIC 100% SV $10/100%PACIFIC LIFE AB 580 PLAN II PREMIER 30 FED COBRA DIS PREMIER 30 FED COBRA EXT PREMIER 30 CAL COBRA EXT PREMIER 30 CAL COBRA DIS SV 15-30/100A PBGH AB PLACER STANDARD PLAN PREMIER 30 CAL COBRA PREMIER 30 PREMIER 30 COBRA 580 PLAN COBRA II $5/250 HMO MFP SJHS NCAL SV 20-30/250A PITNEY 07 SV 20-30/100D PBG VEBA A10 $10/$200/$250 AB RESERVED PPO SP 10/200A SCSV B10 06 $5/250 MFP HMO SJHSNC COBR RX $9/$18G ONLY & NO LIMIT RESERVED 172 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit P3G P3J P3K P3L P3M P3P P3V P45 P4D P4J P4P P4V P4Z P50 P5J P5N P5P P5Q P5R P5S P5V P5Z P6F P6J P6N P6P P6Q P6R P6S P6X P6Y P6Z P7B P7J P7N P7P P7Q P7R P7S P80 P8J P8P P9D P9J P9N P9P P9R P9S P9U P9V Plan / Benefit Description SV 20-30/100D PBG CB SV $15/$250A PBGH AB SV 10/100% SC PAINT 07 SV 10/100% SC PAINT 07 CB SV 10/100% SC PAINT 07 AB RESERVED PPO SP 15/200A SCSVEBA 06 IMPAT. PSYCH. 100% 45 DAYS SV 20-30/250A PITNEY 07 CB SV 20/250A PBGH AB RESERVED PPO SP 10/200A SCSV A10 06 PBGH 20 PLAN COBRA INPAT. PSYCH. 50% 45 DAYS SV 20/250A PBGH AB KEC PLACER CG GR07 RESERVED PPO SV 20/100% SC PAINT 07 KEC PLACER CGII GR07 KEC PLACER CGEH GR07 SP 15/200A SCSVEBA 06 PBGH 15 PLAN COBRA SV 15-20/100A PRDNTL 06 SVA 20/250A PBGH AB KEC PLACER EP CG GR07 RESERVED PPO SV 20/100% SC PAINT 07 CB KEC PLACER EP CGII GR07 KEC PLACER EP CGEH GR07 SV 15-20/100A PRDNTL 06 AB SV 15-20/100A PRDNTL 06 CB PBGH COBRA MC COMP 4 PART B SH07 VEBA B10 $10/$200/$250 AB KEC PLACER PP CG GR07 RESERVED PPO SV 20/100% SC PAINT 07 AB KEC PLACER PP CGII GR07 KEC PLACER PP CGEH GR07 INPATIENT PSYCHIATRIC 80% $15/$250A AB RESERVED PPO SV 20-30/250A PITNEY 07 AB SV PHS $15-$30/$100A AB KEC PLACER DX CG GR07 RESERVED PPO KEC PLACER DX CGII GR07 KEC PLACER DX CGEH GR07 SV 25-35/250A 07 SV 25-35/250A 07 CB 173 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit P9W PA2 PA3 PA4 PA5 PA6 PA7 PA8 PA9 PAA PAB PAC PAD PAE PAF PAG PAH PAI PAJ PAK PAL PAM PAN PAO PAP PAQ PAR PAT PAU PAW PAX PAZ PB2 PB3 PB4 PB5 PB6 PB7 PB8 PBA PBB PBC PBD PBE PBF PBG PBH PBJ PBK PBL Plan / Benefit Description SV 25-35/250A 07 AB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PPO - PFFS PPO - PFFS PPO ADMINISTRATIVE CHARGE PPO - PFFS PPO - PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS RSERVED FOR PFFS VEBA TRIPLE OPT 10/100A AB RESERVED PFFS SV 20-30/100D PBG 06 SV 15-30/100A PBGH PERSONAL ASSIST. NETWORK SV 20/250A PAUSD 08 SVA 20-40/250D 07 KEENAN COMP PLACER GR07 KEC PLACER EP GR07 SV 15-30/100A PBGH CB KEC PLACER PP GR07 KEC PLACER DELUXE GR07 SV 20-30/100D PBG 06 AB SV 20-30/100D PBG 06 CB PBGH $5/100% PART B: STD I PRESCRIPTION PBGH 20 PLAN PBGH 15 PLAN PBGH PBGH-UNION BANK PBGH-UNION BANK COBRA PBGH-MERVYNS BROKER COMMISSION SPECIAL PBGH-MERVYNS COBRA PBGH-MCKESSON ENDORSED PART B: RX BENFT PBGH-MCKESSON COBRA ENDORSED- $9/$18 GEN. ONLY PBGH-VONS PBGH-VONS COBRA PBGH-ESCO TECH PBGH-ESCO TECH COBRA 174 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PBM PBN PBO PBP PBQ PBR PBS PBT PBU PBV PBW PBX PBY PBZ PC1 PC2 PC3 PC4 PC5 PC6 PC7 PC8 PCA PCB PCC PCD PCE PCG PCH PCJ PCM PCN PCO PCP PCR PCS PCT PCU PCX PCY PCZ PD1 PD2 PD3 PD4 PD5 PD6 PDA PDB PDD Plan / Benefit Description PBGH-BECHTEL PBGH-BECHTEL COBRA 2005 PART B ONLY PLAN 2002 PART B ONLY PLAN $10/100 PBGH $20/$250 $100 ER PBGH $20/$250 $100ER COBRA PEPSI BOTTLING GROUP PEPSI BOTTLING GROUP $10/100 COBRA $5/100% $5/100% COBRA UNLM GNRC/$1600 BRAND MAX PBGH $5/100% - COBRA SH PLACER STD MED SH PLACER STD MED W/ HI DE SH PLACER PART B STD MED SH PLACER PART B W/ HI DEN SH PLACER PLUS MED SH PLACER PLUS W/ HI DEN SH PLACER PART B PLUS MED PLACER PT B PLUS W/ HI DEN ALREADY USED ALREADY USED SV 25/250A 06 SVA 15-30/200A PHS 06 UNLM GEN/$2000 ANN. BRAND SV 25/250A 06 CB SV PHS $15-$30/$100A SV PBGH $10-100% AB SV $15/$250A PBGH SVA 15-30/200A PHS 06 CB SV 20/250A PAUSD 08 CB SVA 20-40/250D 07 CB PBHI-CUSTOM RATE PLACER CLASSIC I SV $15/$250A PBGH CB SV 20-30/200A PEPSI 07 SV 25/250A 06 AB SVA 15-30/200A PHS 06 AB PPO 90/70 $250 D $15OV CBR PDV DENTAL ONLY PDV CUSTOM DENTAL ONLY PDV VISION ONLY PDV CUSTOM VISION ONLY PDV DENTAL & VISION PDV CUSTOM DENTAL & VISION SV 20-30/200A PEPSI 06 25/250A PBGH GR06 SV 15/100% SC PAINT 07 175 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PDE PDF PDG PDH PDI PDJ PDK PDM PDN PDO PDP PDR PDS PDT PDW PDX PDY PDZ PE1 PE2 PE3 PE4 PE5 PE6 PE7 PE8 PE9 PEA PEB PEC PEE PEG PEH PEI PEJ PEK PEL PEM PEN PEO PEP PER PES PEU PEV PEX PEY PEZ PF2 PF3 Plan / Benefit Description O/3V 1YR POD SH07 SV 20-30/250A 07 SV 10/100% PG&E 08 O/4V 1YR POD SH07 RSERVED FOR PFFS SV PBGH $20-$30/$250A AB SV 20/100% 07 SV 20/250A PBGH O/6V 1YR POD SH07 SV 20/250A PAUSD 08 AB SVA 20-40/250D 07 AB O/4V 1YR POD SH08 O/3V 1YR POD SH08 SV 20/250A PBGH CB O/6V 1YR POD SH08 SV 20-30/200A PEPSI 06 AB SV 20-30/200A PEPSI 06 CB PPO 90/70 $250 D $0 OV CBR EN: $7G/$15B $2000-BRND MX EN: $7G/$20B $2000 COM LMT EN: $8G/$25B $1500 COM LMT EN: $8G/$30B $1500 COM LMT RX ENDRSD $5/10 UNLM G/BR EN: $8G/$30B $1200 COM LMT EN: $8G/$25B $1000 COM LMT EN: $8G/$30B $1000 COM LMT EN: $8G/$30B $750 COMB LMT SV 25/500A 06 RX EBDRSD 7/25 $1600 BRND RX ENDS UNLM GEN/$2000 BRD SV 25/500A 06 CB RX ENDS GEN UNLM/$1600 BRD RX ENDS UNLM GEN/$1500 BRD RX ENDRSD 5/20 $1000 BRND SV PBGH 20-35/100A AB RX ENDRSD 5/20 $1500 BRND RX ENDS UNLM GEN/$2000 BRD RX ENDRSD $7/25 $500 CMBND RX ENDS UNLM GEN/$1200 BRD END. NO RX-20% INJECT/CHEM RX ENDS UNLM GEN/$1000 BRD RX ENDS $1000 COMB GEN/BRD RX ENDRSD 7/25 $1500 BRND SV 20-30/200A PEPSI 07 CB SH ENDS UNLM GEN/$1500 BRD SV 25/500A 06 AB $20/Q PHB CREDIT SH08 PPO 90/70 $500 D $0 OV CBR RESERVED PPO RESERVED PPO 176 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PF4 PF5 PF6 PF7 PF8 PF9 PFA PFB PFC PFD PFE PFF PFG PFH PFI PFJ PFK PFL PFM PFX PFY PFZ PG2 PG3 PG4 PG5 PG6 PG7 PG8 PG9 PGA PGB PGC PGD PGE PGF PGG PGH PGI PGJ PGK PGL PGM PGN PGO PGP PGQ PGR PGS PGT Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SVA 20/250A 06 SVA 20/250A 06 CB SV 20/250A 06 SV 20/250A 06 CB SV 10/100% PEBT 07 SV 10/100% PEBT 07 CB SV 10/100% PEBT 07 AB SV 20-40/90% ALVA HOS 07 RSERVED FOR PFFS SV PBGH $25/$250A AB SV 20/100% 07 CB DUMMY $500 GENERIC/BRAND ANN MAX SVA 20/250A 06 CB SV 20/250A 06 AB PPO 80/60 $250 D $0 OV CBR $10/100% $10/100% COBRA $20/$250 $20/$250 COBRA ADVANTAGE $20/$250A ADVANTAGE $20/$250A COBRA $15/$250A $15/$250A COBRA $9G/$30B G-UNLIM/B$1000 RX $9G/$25B $2000 COMB LMT $5G/$10B G/B UNLIMITED $9/$18G ONLY & NO LIMIT END. RX-$9/$18GENERIC ONLY $5G/$10B G-UNLIM/B $1000 $9G/$30B G-UNLIM/B$500 $5G/$10B G-UNLIM/B $500 $9G/$40B G-UNLIM/B$350 $5G/$10B G-UNLIM/B $400 SV 10/100% 06 2004 MID YR SH RX CHANGE $9G/$30B G-UNLIM/B $1,300 $9/$18G ONLY & NO LIMIT RX $9/$18G ONLY & NO LIMIT PERF GUARANTEE PENALTY ADM SV 10/100% 06 CB $9G/$40B G-UNLIM/B $500 $9/$18G ONLY & NO LIMIT $9G/$40B UNLIM-CUSTM MEDS 177 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PGV PGX PGZ PH2 PH3 PH4 PH5 PH6 PH7 PH8 PH9 PHA PHB PHC PHD PHF PHG PHH PHI PHJ PHK PHL PHM PHP PHR PHS PHT PHV PHW PHX PHY PHZ PIE PIF PIG PIH PII PIJ PIK PIL PIM PIN PIO PIP PIQ PIR PIT PIU PIV PIW Plan / Benefit Description $9G/$30B G-UNLIM/B-UNLIM SV 10/100% 06 AB PPO 80/60 $250 D $15OV CBR RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20-40/200A PHS 06 SVA 20/250A 06 SV 20-40/200A PHS 06 CB SVA 20/250A 06 CB SP 10/80% PVH 06 SP 10/80% PVH 06 CB SP 10/80% PVH 06 AB RSERVED FOR PFFS SV PBGH $20/$250A AB SV 20-30/250D PETCO 07 $9G/$30B G-UNLIM/B $1,300 SVA 25/500A PBGH 08 SV 10/80% PVH 05 CB PAC ADVAN PREF PLAN CCOBRA $9/$18 GEN ONLY & NO LIMIT PAC ADVAN PREF PLAN $45/Q PHB CREDIT SH07 PAC ADVAN PREF PLAN COBRA SVA 20/250A 06 AB SV 20-40/200A PHS 06 AB PPO 80/60 $500 D $0 OV CBR RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESEVED RX PFFS RESERVED RX PFFS SVA $20/$250A PBGH AB RESERVED RX PFFS RESERVED RX PFFS $1000 GENERC/BRAND ANN.MAX RESERVED RX PFFS RESERVED RX PFFS RSERVED FOR PFFS RSERVED FOR PFFS RSERVED FOR PFFS RSERVED FOR PFFS RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX 178 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PIX PIY PIZ PJ6 PJC PJD PJF PJH PJI PJJ PJK PJM PJP PJQ PJR PJS PJX PJZ PK1 PK2 PK3 PK4 PK5 PK6 PK7 PKA PKE PKF PKG PKI PKJ PKK PKL PKM PKN PKS PKU PKV PKX PKZ PL1 PL5 PLA PLB PLC PLD PLE PLF PLG PLH Plan / Benefit Description RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX SV 15/100% SC PAINT 06 AB SV 20-35/100A 06 SV 20-35/100A 06 CB SV 20/100% POWER 07 SV 20-40/90% ALVA HOS 07CB RSERVED FOR PFFS SVA 20-30/250A PITNEY AB SV 20/100% 07 AB SV 20-40/300A PEPSI 08 SV 20-30/100D PBG 07 SV 20-40/300A PEPSI 08 CB SV 20-40/300A PEPSI 08 AB SV 20-30/250A PETCO 07 SV 20-35/100A 06 AB NAT'L PPO $15OV 80/60 CBRA HMO 30 HMO 30 COBRA HMO 30 CAL COBRA HMO 30 FED COBRA DIS HMO 30 FED COBRA EXT HMO 30 CAL COBRA EXT HMO 30 CAL COBRA DIS SV 15-25/100A 06 SV 25/250A 07 SV 20-30/250A 07 CB SV 10/100% PG&E 08 CB RSERVED FOR PFFS HMO 30 PLAN AB SV 20-30/250D PETCO 07 CB SV 15-25/100A 06 CB SV 20/250A PBGH CB RX UNLM GEN/$1500 BR $7/20 SV 20-30/250A PETCO 07 CB HMO 30 USERRA UNLM GEN/$1500 ANN BRAND SV 15-25/100A 06 AB NAT'L PPO $15OV 90/70 CBRA PPO CUSTOM 500 SERIES SV $10/100%PACIFIC LIFE CB PLACER COUNTY BASIC PLAN PLACER COUNTY-PRT B ONLY PPO 90/70 $250 DED $15OV PPO 90/70 $250 DED $0 OV PPO 90/70 $500 DED $0 OV PPO 80/60 $250 DED $0 OV PPO 80/60 $250 DED $15 OV PPO 80/60 $500 DED $0 OV 179 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PLI PLJ PLK PLL PLM PLN PLP PLS PLV PLW PLX PLZ PM1 PM2 PM3 PM4 PM5 PM6 PM8 PM9 PMA PMB PMC PMD PME PMF PMG PMH PMI PMJ PMK PML PMM PMN PMO PMP PMQ PMR PMS PMT PMU PMW PMX PMZ PN6 PNB PNC PNE PNF PNG Plan / Benefit Description RSERVED FOR PFFS NAT'L PPO $15OV 80/60 NAT'L PPO $15OV 90/70 SV 15/250A 06 SVA 20/250A PBGH CB SV $10/100%PACIFIC LIFE PAYMENT LAG PREMIUM ALLOC $5G/$20B GEN/BRAND UNLIM. $9G/$30B/$55NF UNLIMITED SV 15/250A 06 CB SV 15/250A 06 AB PPO CUSTOM 500 SERIES CBRA PERS- RET. MED. SH BENEFIT SV PBGH $20/250A CB SV PBGH $10-100% CB SV PBGH $20-$30/$250A CB SV PBGH 20-35/100A CB SV PBGH $25/$250A CB SV PBGH $20/$250A CB SVA $20/$250A PBGH CB SR PREMIER MARIN PT B SV PBGH $20/250A SV PBGH $10-100% SV PBGH $20-$30/$250A SV PBGH 20-35/100A SV PBGH $25/$250A SVA 15/250A 07 SV PBGH $20/$250A SVA $20/$250A PBGH SV PBGH $20/250A AB SV 20/250A PBGH SVA 20/250A PBGH SR PREMIER MARIN SV PBGH $20/$250A SVA PBGH $20/$250A 25/250A PBGH NON-AARP GR08 SV PBGH $10/100% $1000 GENERC/BRAND ANN.MAX SV $20/$250A PBGH SV $25/250A PBGH SV PBGH $5/100% SV25-35/250A PBGHMRVYNS PPO 90/60 STANDARD PLAN PPO 90/60 STANDARD PLAN CB NO. CA: $8G/$30B $1200 MAX RX UNLM GEN/$1600 BR $7/25 UNLM GEN/$2100 ANN. BRAND SVA 20-30/250A PITNEY SV 20/100% POWER 07 CB SV 20-30/250A 180 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PNH PNI PNJ PNK PNM PNS PNZ POD POE POF POG POH POI POJ POK POL PON POO POQ POR POS POT POU POV POW POX POY POZ PP1 PP2 PP5 PPA PPB PPC PPD PPE PPF PPG PPH PPI PPJ PPK PPL PPM PPN PPP PPQ PPR PPS PPT Plan / Benefit Description SV 15/100% 07 RSERVED FOR PFFS SV PBGH $20/$250A AB SV 20-30/250D PETCO 07 AB SVA 25/500A PBGH 08 CB SV 20-30/250A PETCO 07 AB SV PBGH $20/$250A CB RSERVED FOR PFFS RSERVED FOR PFFS RSERVED FOR PFFS RSERVED FOR PFFS RSERVED FOR PFFS RSERVED FOR PFFS SVA PBGH $20/$250A AB 10/6V 1YR GR-PD07 RSERVED FOR PFFS RSERVED FOR PFFS RSERVED FOR PFFS RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX RESERVED PFFS RX SVA PBGH $20/$250A CB SH PLUS MED PODIATRY 2002 SH PLUS-PODIATRY PLAN SV 20/250A 06 CB RESERVED PPO SO.CAL.PLUS PLAN NO PRT A 580 PLAN/$800-$2400 MAX RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RSERVED FOR PFFS SV 20/250A 06 AB RESERVED PPO RESERVED PPO RESERVED PPO PACIFICARE PPO NETWORK SV 20/250A 06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 181 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PPU PPV PPW PPX PPY PPZ PQA PQE PQF PQG PQH PQI PQJ PQL PQM PQP PQX PQZ PR0 PR1 PR5 PR6 PR7 PRA PRB PRC PRD PRE PRF PRG PRI PRJ PRL PRN PRP PRS PRX PRZ PS1 PS2 PS3 PS4 PS5 PS6 PS7 PS8 PS9 PSA PSB PSC Plan / Benefit Description RESERVED PPO RESEREVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 580 PLAN/$800-$2400 MAX SV 20/250A PRVDNCE 06 SV 25/250A 07 CB SV 20-30/250A CB SV 10/100% PG&E 08 AB SV 20-40/90% ALVA HOS 07AB RSERVED FOR PFFS SV PBGH $10/100% CB SV 20-40/250A 07 SV PBGH $10/100% CB 10 PUPLIC SECTOR AARP GR08 SV 20/250A PRVDNCE 06 AB SV 20/250A PRVDNCE 06 CB PREFERRED PLAN INACTIVE PREFERRED PLAN RX UNLIM.ANNUAL MAX $5/$10 SV 25-40/250A PBGH SV 25-40/250A PBGH CB $9G/$30B/$55NF-G-UNLM/B500 $9G/$30B/$55NF-G ULM-B1000 $15/$30 GEN ONLY-NO LIMIT PREMIUM DELAY SV 20/250A 06 PPO RENTAL NETWORK FEE $5G/$20B GEN-UNLIM/B $1000 RX CMBND $1000 G/BR $7/25 SV 25-40/250A PBGH AB SV 20-40/250A 07 CB RX UNLM GEN/$1200 BR $7/25 SV 20/250A 06 CB PPO CUSTOM RET SAN DIEGO SV 20/250A 06 AB PPO CUSTOM RET S DIEGO CBR PERS PLAN (PREFERRED) RX $7G/15B $2000 BRAND MAX RX $7G/$20B $2000 COMB LMT RX $8G/$25B $1500 COMB LMT RX $8G/$30B $1500 COMB LMT RX $8G/$30B $1200 COMB LMT RX $8G/$25B $1000 COMB LMT RX $8G/$30B $1000 COMB LMT RX $8G/$30B $750 COMB LIMT SO.CAL SENIOR PLAN PLUS SR PREMIER SOL/SOM PART B RX UNLM GEN/$2000 BR $7/15 182 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PSD PSE PSF PSG PSJ PSL PSM PSN PSP PSQ PSR PSS PST PSV PSZ PTA PTB PTC PTE PTF PTH PTI PTJ PTN PTW PTX PTY PTZ PU2 PU6 PUA PUB PUC PUD PUE PUF PUG PUH PUI PUJ PUK PUL PUM PUN PUP PUQ PUX PUY PUZ PV2 Plan / Benefit Description PPO CUSTOM SAN DIEGO END. RX $9G/$25B $2000 LMT SV 20/100% POWER 07 AB $9/$18 GEN ONLY & NO LIMIT SV $20/$250A PBGH AB UNLM GNRC/$1500 BRND MAX. SH $1000 COMB GEN/BR $7/25 $9G/$40B/$65NF-G-UNLM/B350 SV 20/200A PEPSICO SV 20/200A PEPSICO CB RX UNLM GEN/$2000 BR $7/20 SR PREMIER SOLANO/SONOMA PUBLIC SECTOR $10 GRP RET SH UNLM GEN/$1500 BR $7/25 PPO CUSTOM SAN DIEGO COBRA SV 25/500A PBGH 08 2003 PART B ONLY PLAN SV 20-30/250A PETCO 08 SV 25/500A PBGH 08 CB SV 25/500A PBGH 08 AB SV 20-30/250A PETCO 08 CB RSERVED FOR PFFS SV $25/250A PBGH AB SVA 20-30/250A PITNEY CB SV 15/100% PAC LIFE 07 CB SV 15/100% PAC LIFE 07 AB SV 20-30/250A PETCO 08 AB PEP BOTTLING GROUP COBRA SV 10/100% SC PAINT 06 AB SV 15/100% SC PAINT 06 SV 10/100% PRVDNCE 06 SV 20-40/500D 07 SV 10/100% SC PAINT 06 MCC PLACER DELUXE SH07 MCC PLACER EP SH07 SV 20-30/250A 07 AB SV 15/100% SC PAINT 07 CB SV 15/100% 07 CB RSERVED FOR PFFS SV PBGH $5/100% AB SV 20-40/500D 07 CB SV 20-30/200A PEPSI 07 AB SV PBGH $5/100% CB MC COMP PLACER SH07 MCC PLACER PP SH07 SV 20-40/500D 07 AB SV 10/100% PRVDNCE 06 AB SV 10/100% SC PAINT 06 CB SV 10/100% PRVDNCE 06 CB VEBA A10 $10/$200/$250 183 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PV3 PV4 PV5 PV6 PV7 PV8 PV9 PVA PVB PVC PVD PVE PVF PVG PVH PVI PVJ PVK PVL PVN PVP PVR PVS PVT PVU PVV PVX PVY PVZ PW1 PW2 PW3 PW4 PWA PWC PWD PWE PWF PWG PWH PWI PWJ PWK PWL PWM PWN PWP PWU PWW PWX Plan / Benefit Description VEBA A10 $10/$200/$250 CB VEBA A15 $15/$200/$500 VEBA A15 $15/$200/$500 CB VEBA B10 $10/$200/$250 VEBA B10 $10/$200/$250 CB VEBA B15 $15/$100/$500 VEBA B15 $15/$100/$500 CBR VEBA TRIPLE OPT 10/100A VEBA TRIPLE OPT 10/100A CB SV 20/250A 06 SV 20-30/250A AB SP 10/200A SCSV B10 06 CB SV 25/250A PBGH 08 SP 15/200A SCSVEBA 06 CB SV 10/80% PVH 05 RSERVED FOR PFFS SV 20/200A PEPSICO AB SP 10/200A SCSV B10 06 AB SP 10/200A SCSV A10 06 CB SV 25/250A PBGH 08 CB SV 25/250A PBGH 08 AB $9G/$40B/$65NF-G UNLM-B500 $5G/$20B GEN-UNLIM/B $500 SP 15/200A SCSVEBA 06 CB SP 10/200A SCSV A10 06 CB SP 15/200A SCSVEBA 06 AB SV 20/250A 06 AB SP 15/200A SCSVEBA 06 AB SV 20/250A 06 CB PPO SAN DIEGO RETIREES PPO SN DIEGO RETIREE COBRA NATL PPO SAN DIEGO RETIREE NATL PPO SN DIEGO RET COBR NATL PPO 80/60-80/70 $250D SV 15-25/100A 07 SV 15-25/100A 07 CB PLACER CLASSIC I W/EPO DDS SVA 20-40/500D 07 SVA 15/250A 07 CB SV 15-25/100A 07 AB RSERVED FOR PFFS SV25-35/250A PBGHMRVYNS AB SVA 20-40/500D 07 CB SV 15/100% SC PAINT 07 AB SV25-35/250A PBGHMRVYNS CB SVA 20-40/500D 07 AB PLACER CLASSIC I W/ODP ARP MCC PLACER PP SH08 ARP MCC PLACER SH08 ARP MCC PLACER DLX SH08 184 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit PWY PWZ PX1 PX2 PX3 PX4 PXA PXC PXE PXG PXH PXI PXJ PXL PXM PXP PXS PXY PXZ PYA PYB PYC PYE PYH PYI PYJ PYX PYY PYZ PZ1 PZ4 PZ6 PZA PZB PZH PZJ PZL PZP PZS PZT PZU PZX PZZ Q1C Q1I Q1J Q1P Q1Y Q1Z Q2B Plan / Benefit Description ARP MCC PLACER EP SH08 NA PPO 80/60-80/70 250D CB NATL PPO CUSTOM S DIEGO NATL PPO CUSTOM S DIEGO CB NATL PPO CUSTOM RET S DIEG NATL PPO CUSTOM RET SD CBR NATL PPO CUSTOM 500 SERIES SV 15/100% PAC LIFE 07 SV 25/250A 07 AB SVA 15/250A 07 AB SV 15/100% 07 AB RSERVED FOR PFFS $5/100% AB SV 20-40/250A 07 AB SVA 25/500A PBGH 08 AB SV 20-30/100D PBG 07 CB SV $20/$250A PBGH CB $30/Q PHB CREDIT SH08 NATL PPO CUSTOM 500 CBR NATL PPO 90/70-90/80 $250D SV 20/100% SC PAINT 06 SV 20-40/500A 07 SV 20-40/500A 07 CB SV 20-40/500A 07 AB RESERVED PFFS SV 20-30/100D PBG AB SV 20/100% SC PAINT 06 AB SV 20/100% SC PAINT 06 CB NA PPO 90/70-90/80 250D CB PREFERRED PLAN (COBRA) SV 10/100% PACIFIC 06 AB SV 15/100% SC PAINT 06 CB SV 25-35/250A 06 SV 25-35/250A 06 CB SV PHS $15-$30/$100A CB PEPSI BOTTLING GROUP AB SV 10/100% PACIFIC 06 SV 20-30/100D PBG 07 AB PERS PLAN PREFERRED/COBRA SV $25/250A PBGH CB PEPSI BOTTLING GRP COBRA SV 25-35/250A 06 AB SV 10/100% PACIFIC 06 CB 1500 PLAN II INDIVIDUAL CONVERSION 1500 PLAN AB 1500 PLAN 1500 PLAN 1500 PLAN COBRA II SV 20/250A+20% KMSTF 05 CB 185 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit Q2C Q2J Q2Z Q31 Q3C Q3J Q3Y Q3Z Q4C Q4J Q4Z Q5C Q5J Q5Z Q67 Q6C Q6J Q6Z Q7J Q7N Q7Z Q8J Q9J QA4 QA5 QAC QAH QAJ QAQ QAZ QBB QBH QBJ QBQ QCA QCH QCJ QCQ QDA QDE QDG QDJ QEA QEE QEG QEJ QFA QFB QFE QFF Plan / Benefit Description MFP 1500 PLAN SV $20/80% AB MFP 1500 PLAN (COBRA) POMONA VLY HOSP 100/80/60 NON-STANDARD 1500 PLAN SV $10/100% AB POMONA HOSP 100/80/60 CBR NON-STANDARD 1500 PLAN CBR NON STANDARD 20/150 SV $20-$40/$250A AB NON STANDARD 20/150 CBRA PBGH $20/$250 $50 ER SV 20/100% AB PBGH $20/$250 $50 ER COBRA SV 20/80% 06 AB SHEET METAL WORKERS $20 SHEET METAL WORKERS $20 AB SHEET METAL WORKERS $20 CB SV 15/250A PORTFOLIO AB NON-STD $20 HMO NON-STD $20 HMO COBRA SV 20/250A+20% KMSTF 05 AB SV 20-40/250D PORTFOLIO AB SV $20/$40/$250A SV $20/$40/$250A CB $20/$250 HMO 2000 SER SV 20/100% 07 SV $20/$40/$250A AB SV 30/500A 07 $20/$250 HMO 2000 SER CBRA SV 20/250A+20% KMSTF 05 SV 20/100% 07 CB SV 20/250A AB SV 30/500A 07 CB SVA 20/100% 07 SV 20/100% 07 AB $20/$250 HMO 2000 SER AB SV 30/500A 07 AB SVA 20/100% 07 CB SV 10/100% 07 SPT 10-25/100% SD 07 SV $20-$40/$400D AB SVA 20/100% 07 AB SV 10/100% 07 CB SPT 10-25/100% SD 07 CB SV 30/500A AB SVA 30/500A 07 SV 15/250A 07 SV 10/100% 07 AB SVT 15-35/250A NONSD 07 186 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit QGA QGB QGF QGJ QHA QHB QHF QHG QIJ QJG QKG QKH QLA QLB QLH QLJ QMA QMB QMG QMH QNA QNB QNJ QPJ QPP QPY QQ3 QQ4 QQ5 QQ6 QQ7 QQ8 QQ9 QQA QQB QQC QQE QQF QQG QQH QQI QQJ QQK QQL QQM QQN QQO QQP QQR QQS Plan / Benefit Description SVA 30/500A 07 CB SV 15/250A 07 CB SVT 15-35/250A NONSD 07 CB SV 20-40/500D PORTFOLIO AB SVA 30/500A 07 AB SV 15/250A 07 AB SVT 15-35/250A NONSD 07 AB SVA 10/100% 07 SVA 10/100% AB SVA 10/100% 07 CB SVA 10/100% 07 AB SPT 10-25/100% NONSD 07 SV 20-40/250D 07 SVT 15-35/250A SD 07 SPT 10-25/100% NONSD 07 CB SVA 20-100% AB SV 20-40/250D 07 CB SVT 15-35/250A SD 07 CB SPT 10-25/100% SD 07 AB SPT 10-25/100% NONSD 07 AB SV 20-40/250D 07 AB SVT 15-35/250A SD 07 AB SVA 15/250A PORTFOLIO AB SVA 20-40/250D PORTFOLI AB PEPSICO CHOICE PLAN PEPSICO CHOICE COBRA SV $10/100% SV $10/100% CB SV 20/100% SV 20/100% CB SV 15/250A PORTFOLIO SV 15/250A PORTFOLIO CB SV 20-40/250D PORTFOLIO SV 20-40/250D PORTFOLIO CB SV 20-40/400D PRES HOS 05 SV 20-40/400D PRES 05 CB SV 30/500A SV 30/500A CB SV 20-40/500D PORTFOLIO SV 20-40/500D PORTFOLIO CB SVA 10/100% SV 20-40/400D PRES 05 AB SVA 10/100% CB SVA 20-100% SVA 20-100% CB SVA 15/250A PORTFOLIO SVA 15/250A PORTFOLIO CB SVA 20-40/250D PORTFOLI SVA 30/500A SVA 30/500A CB 187 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit QQT QQU QQV QRJ QTJ QUA QUJ QUZ QV2 QV3 QVA QVB QVJ QVX QW2 QW3 QW4 QW5 QW6 QW7 QWB QWC QWD QWE QWF QWG QWJ QYB QYC QYJ QZJ R01 R02 R03 R04 R05 R06 R07 R08 R09 R0A R0B R0C R0D R10 R1C R1J R1S R1Z R23 Plan / Benefit Description SVA 20-40/500D SVA 20-40/500D CB SVA 20-40/250D PORTFOLI CB SVA 30/500A AB SVA 20-40/500D AB SP 15/200A QUIDEL 06 SP 15/200A QUIDEL 06 AB SP 15/200A QUIDEL 06 CB SV 20/250A SCS VEBA 06 CB SP 25/250A SCS VEBA 06 CB SV 20/250A SCS VEBA 06 SP 25/250A SCS VEBA 06 SV 20/250A SCS VEBA 06 AB SP 25/250A SCS VEBA 06 AB SV $20/80% SV $20/80% CB SV $20-$40/$250A SV $20-$40/$250A CB SV 20/80% 06 SV 20/80% 06 CB SV 20/250A SV 20/250A CB SV $20-$40/$400D SV $20-$40/$400D CB SV 20/250A 06 SV 20/250A 06 CB SV 20/250A 06 AB SP 10/100% PIH 05 SP 10/100% PIH 05 CB SP 10/100% PIH 05 AB MFP 1500 PLAN AB $5G/$10B/$25NF $5G/$5B $5G/$10B/$20NF $5G/$15B/$25NF $10G/$10B $10G/$20B/$40NF $20G/$30B 20G/35B/100 DED $20G/$30B/$50NF 20G/35B/50NF/100 $5G/$5B $10G/$15B $10G/$25B/$35NF MFP $10 $10/$100 HMO 2000 SER $10/$100 HMO 2000 SER AB RIVERSIDE STANDARD PLAN $10/$100 HMO 2000 SER CBRA DUMMY CODE - OK TO USE 188 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit R24 R25 R2C R2J R2S R2Z R3C R3J R3P R3S R3U R4J R4P R4S R5P R5S R64 R65 R66 R67 R6E R6J R6S R74 R75 R76 R77 R7E R7J R7S R84 R85 R86 R87 R8D R8E R8H R8J R8L R8N R9D R9E R9H R9L R9N RA2 RAD RAE RAF RAG Plan / Benefit Description DUMMY - OK TO USE O/P PRESCRIP DRUGS $2.50 $10/$250 HMO 2000 SER $10/$250 HMO 2000 SER AB RIVERSIDE STANDARD - II $10/$250 HMO 2000 SER CBRA CALPERS RET$5G/$15B/$30NF SV 10/100A AB 0/90H 1 YR RESPITE GR07 RIVERSIDE PLUS PLAN $10G/$20B/$35NF GRP RET SV 10/250A AB 0/50H 1 YR RESPITE GR07 RIVERSIDE STD. W/OPT DDS 0/40-100H 1YR RESPITE GR07 RIVERSIDE STAND. W/HI DENT KEC 1 RVERSDE CG GR07 KEC 1 RVERSDE LO CG GR07 KEC 1 RVERSDE HI CG GR07 KEC 1 RVERSDE DX CG GR07 SV 10/100A 06 SV 10/100A 06 AB RIVERSIDE PLUS W/OPT DENTL KEC 1 RVERSDE CGII GR07 KEC 1 RVERSDE LO CGII GR07 KEC 1 RVERSDE HI CGII GR07 KEC 1 RVERSDE DX CGII GR07 SV 10/100A 06 CB SV $10-$20/$100D AB RIVERSIDE PLUS W/HI DENTAL KEC 1 RVERSDE CGEH GR07 KEC 1 RVERSDE LO CGEH GR07 KEC 1 RVERSDE HI CGEH GR07 KEC 1 RVERSDE DX CGEH GR07 MCC 2 RIVERSDE DELUXE SH07 SV 10/250A 06 MCC 2 RIVERSDE HIGH SH07 SV 10/250A 06 AB MCC 2 RIVERSDE LOW SH07 MC COMP 2 RIVERSIDE SH07 MCC 3 RIVERSDE DELUXE SH07 SV 10/250A 06 CB MCC 3 RIVERSDE HIGH SH07 MCC 3 RIVERSDE LOW SH07 MC COMP 3 RIVERSIDE SH07 $7/$7 SV 20/90% RITE AID 07 SV 20/90% RITE AID 07 CB SV 15-25/250A ROSS 07 SV 20/90% RITE AID 07 AB 189 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit RBA RBH RBJ RBZ RC1 RC2 RC3 RC4 RC5 RC7 RCA RCB RCC RCD RCE RCF RCG RCH RCI RCJ RCK RCL RCM RCN RCO RCP RCQ RCS RCT RCU RCV RCW RCY RCZ RDA RDB RDD RDE RDF RDG RDH RDJ RDL RDN RDZ RE1 RE2 RE3 RE4 RE5 Plan / Benefit Description SV 20/100A ROCHE PAL 06 20 ROCHE PA NON-AARP GR08 SV 20/100A ROCHE PAL 06 AB SV 20/100A ROCHE PAL 06 CB RETAIL CLERKS PLAN RETAIL CLERK DRUG PLAN $5G/$15B/$30NF CALPERS RET ROSS STORES ADV 15/250A ROSS STORES ADV 15/250A CB $7 RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM $2 FLAT RX RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM SV 30/500A RESIG 06 20/100A ROCHE PA GR06 MCC ESS RVRSDE DLUXE SH07 SP 10/100% RUSD 07 SV 15-25/250A ROSS 07 CB SV 25/250A RETA 07 MCC ESS RVRSDE HIGH SH07 SV 15/100% RUSD 05 AB MCC ESS RVRSDE LOW SH07 MC COMP ESS RVRSDE SH07 SV $15/100% RIVERSIDE CB RETAIL CLERKS-EXT. OB CARE SV 10/100A SV 10/100A CB SV 10/250A RETIREE RX 5/10 $1600 BRND 190 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit RE6 RE7 RE8 REA REC REF REK REP REV REX REZ RF0 RF1 RF2 RF3 RF4 RF5 RF6 RF7 RFA RFB RFC RFD RFE RFF RFG RFH RFL RFM RFN RFS RFU RFW RFX RFY RFZ RG1 RG2 RG3 RG4 RG5 RG6 RG7 RG8 RG9 RGA RGB RGC RGD RGE Plan / Benefit Description SV 10/250A CB SV $10-$20/$100D SV $10-$20/$100D CB SV 30/500A RESIG 06 CB REED $10 SH RETIREE EDISON FLX CSTM SP 10/100% RUSD 06 SP 10/100% RUSD 06 CB SP 10/100% RUSD 06 AB SH RETIREE EDISON FLEX $5 SV 20/250A RESIG 06 RX RETIREE $0G/$0B UNLM MF RX RETIREE $1G/1B UNLMD MF RX RETIREE $2G/2B UNLMD MF RX RETIREE $3G/3B UNLMD MF RX RETIREE $4G/4B UNLMD MF RX RETIREE $5G/5B UNLMD MF RX RETIREE $6G/6B UNLMD MF RX RETIREE $7G/7B UNLMD MF $10G/$20B RET $250 INJ RET.GOLD TRW EH790 RX RETIREE $5G/$10B UNLMD $5G/$20B RET $250INJ RX RETIREE $5G/$10B $1600B RX RETIREE $7G/10B $1600B RX RETIREE $7G/10B $2500B RX $10G/$10B $250 INJ RX RETIREE $5G/$20B UNLMD RX RETIREE $5G/10B UNLM MF RX RETIREE $5G/15B UNLMD RX RETIREE $7G/$10B $2500B RX RETIREE $7G/10B UNLIM RX RETIREE 3G/5B UNLMTD MF RX RETIREE $10G/10B UNLMD RX RETIREE $10G/20B UNL MF SV 20/250A RESIG 06 CB RETIREE GOLD BAS-PLUS NO C RETIREE GOLD CUST/DEN N CA RG PLUS SO CAL RG PLUS SO CAL NO PAY RG PLUS SO CA - CUSTOM RG PLUS SO CA - CUSTOM RG BASIC PLUS CUSTOM RG PREMIER CUSTOM RG PREMIER SO CALIF RETIREE GOLD CUSTOM RETIREE GOLD BASIC SO CA RG CUSTOM RETIREE GOLD S-DENT SO CA RETIREE GOLD W/DENT NO CAL 191 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit RGN RGP RGT RGX RH1 RH2 RHB RHC RHD RHE RHF RHG RHH RHJ RHR RHZ RIB RJA RJB RJC RJE RJF RJJ RK1 RK2 RKD RKH RKL RKN RL2 RLA RLB RLE RLF RLM RLR RLS RLT RLU RM0 RM1 RM2 RM3 RM4 RM5 RM6 RM7 RMA RMD RMF Plan / Benefit Description RETIREE GOLD BASIC NO CAL RETIREE GOLD RX SO CA SH RETIREE GMP $5G/10B CF $10G/$10B GRP RET RET.GOLD HRNG A1325 RET.GOLD F2191 HEARING SV 15/250A RETA 07 ROHR PLAN ROHR $10 ROHR $10 - COBRA $5 RX CO-PAY/$1500 AN.MAX. ROHR $20 ROHR $20 - COBRA ROHR $10 AB RX CSTM GMP TRUST 5/10 ROHR PLAN - COBRA RX RETIREE SO CA IBEW SV 10/100% CRYROP 06 SV 15/250A RETA 07 CB KEENAN COMP 1 RVERSDE GR07 SP 10/100% RUSD 07 CB SV 10/100% CRYROP 06 CB SV 10/100% CRYROP 06 AB ROCKWELL PLAN/PREF-50 OPMH STANDARD 10 - $25 ER MCC 1 RIVERSDE DELUXE SH07 MCC 1 RIVERSDE HIGH SH07 MCC 1 RIVERSDE LOW SH07 MC COMP 1 RIVERSDE SH07 PLACER II STANDARD PLAN $5G/$7.50B SV 15/250A RETA 07 AB SP 10/100% RUSD 07 AB SV 15-25/250A ROSS 07 AB RX RETIREE LORAL CUSTOM RX RETIREE LACERS 5/10 OPN RX RETIREE - LORAL SPACE $5G/$5B GRP RET $5G/$10B GRP RET O/P RX $0 SH-RETIREE O/P PRESCRIP $1 (SH-RET) O/P PRESCRIP $2 (SH-RET) O/P PRESCRIP $3 (SH-RET) O/P PRESCRIP $4 (SH-RET) O/P PRESCRIP $5 (SH-RET) O/P PRESCRIP $6 (SH-RET) O/P PRESCRIP $7 (SH-RETIRE SV 30/500A RESIG 06 AB RX CSTM MCDONNELL DOUGLAS SV 25/70% RESIG 06 192 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit RMG RMH RMR RMS RN1 RN2 RN3 RN4 RN5 RN6 RNA RNB RNC RND RNE RNF RNG RNH RNJ RNK RNL RP1 RP2 RP3 RP4 RP5 RP6 RP7 RP8 RP9 RPB RPC RPD RPE RPI RPJ RPM RPN RPO RPP RPQ RPR RPS RPT RPU RPV RPX RPZ RQC RQE Plan / Benefit Description SV 25/70% RESIG 06 CB SV 25/70% RESIG 06 AB $15G/$20B/$30NF RIVERSIDE MEDICAL $7G/$14B GRP RET $10G/$20B GRP RET $10G/$25 GRP RET $10G/$20B/$40NF $10G/$20B/$50NF $15G/$25B/$40NF $7G/$14B GRPRET $10G/$20B GRPRET $10G/$25B GRPRET $10G/$20B/$40NF $10G/$20B/$50NF $15G/$25B/$40NF $7G/$14B $10G/$20B $10G/$25B $10G/$20B/$40NF $15G/$25B/$40NF RG PREMIER SO CAL CUSTOM RG PREMIER SO CAL CUSTOM $3 RETIREE GOLD CUSTOM PLAN RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RG PREMIER SO CALIF CUSTOM RX RETIREE $5G/15B UNLM MF THRIFTY PAYLESS PLAN SV 15-25/250A ROSS 06 RESPITE/PERS CARE SH07 RX RETIREE TPIG $5G/10B UN SV 15-25/250A ROSS 06 AB RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM SV 15-25/250A ROSS 06 CB RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RESPITE/PERS CARE WL-SH08 THRIFTY PAYLESS PLAN COBRA $10/$250 HMO MFP PLAN KEC 1 RVERSDE LOW GR07 193 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit RQH RQL RQW RQX RQZ RR7 RRA RRB RRC RRD RRE RRF RRG RRH RRI RRJ RRK RRL RRM RRN RRO RRP RRQ RRR RRS RRT RRU RRV RRW RRX RRZ RS1 RS2 RS3 RS4 RS5 RS6 RS7 RS8 RSC RSD RSE RSH RSJ RSL RSN RSU RSV RT2 RT6 Plan / Benefit Description ARP MCC 1 RVSIDE HI SH08 ARP MCC 1 RVSIDE LO SH08 ARP MCC 1 RVSIDE SH08 ARP MCC 1 RVSIDE DLX SH08 $10/$250 HMO MFP PLAN COBR SH RETIREE STD $7 RX RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM ROHR PLAN RETIREE GOLD CUSTOM KEC 1 RVERSDE HIGH GR07 RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM ROHR PLAN COBRA SH RIVERSIDE STD MED SH RIVERSIDE STD W/ HI DEN SH RIVERSIDE PART B STD RIVERSIDE PART B W/ HI DEN SH RIVERSIDE PLUS MED RIVERSIDE PL MED W/ HI DEN RIVERSIDE PART B PLUS MED RIVERSIDE PT B PL W/ HI DE RETIREE SH CUSTOM 5/10 SV 15/100% RUSD 05 CB END RIVERS BASIC W/ NO DEN $10G/$15B CUSTOM RX CITY OF SAN JOSE RX CSTM SO.CAL.LABORERS $10G/$20B/$25NF SV $15/100% RIVERSIDE RX RETIREE $5G/10B CUSTOM 10/250 PLAN MFP SV 15/250A RETA 06 194 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit RTA RTC RTE RTG RTJ RTP RTR RTX RTZ RUA RUC RUD RUF RUG RUJ RUL RUS RUT RUZ RVA RVC RVD RVE RVF RVH RVJ RVL RVS RVT RVZ RWA RWD RWE RWH RX0 RX1 RX2 RX3 RX4 RX5 RX6 RX7 RX8 RX9 RXA RXB RXC RXD RXE RXF Plan / Benefit Description RETIREE GOLD CUSTOM RETIREE GOLD CUSTOM KEC 1 RVERSDE DELUXE GR07 SV 25/250A RETA 07 CB 10/250 PLAN MFP AB 5/10 CLOSED RX/UNLIMITED SV 15/250A RETA 06 CB SV 15/250A RETA 06 AB 10/250 PLAN MFP COBRA RX RETIREE UA LOCAL 447 PT RX RETIREE UC $5G/10B CL F $1OG/$20B/$35NF SP 10/100% RUSD 06 SV 25/250A RETA 07 AB SV $15/100% RIVERSIDE AB SP 10/100% RUSD 06 CB SV 15/100% RUSD 05 SP 10/100% RUSD 06 AB SV 20/250A RESIG 06 AB SV 10-20/100D 07 $10/$250 PER ADMIT RVRSDE CLSC ENHNCD W/OPDDS RVRSDE CLSC ENHNCD W/EPDDS SV 10/100% RUSD 06 RVRSDE CLSC ENHNCD W/HIDDS $10/$250 PER ADMIT AB SV 10/100% RUSD 06 CB RIVERSIDE CLSC ENHANCED SV 10/100% RUSD 06 AB $10/$250 PER ADMIT COBRA SV 10-20/100D 07 CB RIVERSIDE MEDICAL W/OP DDS RVRSIDE MEDICAL W/EPO DDS RVRSIDE MEDICAL W/HIOP DDS $0 $1 $2 $3 $4 $5 GENERIC $10 BRND UNLIM. $6 $7 $8 $9 RX SO.CAL.MAX RX SACRAMENTO MAX. RX NO.CAL.MAX $1500 ANNUAL MAX $1400 ANNUAL MAX. $1200 ANNUAL MAX. 195 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit RXG RXH RXI RXJ RXK RXL RXM RXN RXO RXP RXR RXS RXT RXU RXV RXX RXY RXZ RYA RYH RYL RYW RYX RZ1 RZ2 RZC RZJ S10 S1A S1C S1D S1E S1F S1G S1J S1L S1M S1P S1R S1T S1U S1X S1Y S1Z S2B S2C S2D S2E S2F S2J Plan / Benefit Description $1000 ANNUAL MAX. $800 ANNUAL MAX. $5 RX/$1500 ANNUAL MAX. $5 WALK-IN MANAGED CL RX $10 WALK-IN MNGD CL RX S.H. O/P PRESCRIPT DRUGS S.H. O/P PRESCRIP SAN DIEG $5G/$10B/$20NF PRESCRIPTION BENEFIT ONLY $7/$10 GENERIC/FORMULARY $5/$5 GENERIC/BRND/FORM. RETIREE RX $5/$15 SH O/P PRESCRIPT DRUG $7 GENERIC/UNLIMITED $10G/$20B GRP RET SH O/P PRESCRIPT $5/$1500 SH O/P PRESCRIPT $5/$1200 $5 RX CO-PAY/$2500 ANN.MX. SV 10-20/100D 07 AB ARP MCC 3 RVSIDE HI SH08 ARP MCC 3 RVSIDE LO SH08 ARP MCC 3 RVSIDE SH08 ARP MCC 3 RVSIDE DLX SH08 RETAIL CLERKS PLAN (COBRA) RETAIL CLERK DRUG PLAN CBR REED $10 - COBRA ROHR PLAN AB STANDARD 10 PLAN SANTA CLARA STANDARD PLAN PBGH 15 PLAN SAN DIEGO STANDARD - I SAN BERNARDINO STANDARD SAN FRANCISCO STANDARD SAN DIEGO STANDARD-III SAN JOAQUIN STANDARD PLAN SAN LUIS OBISPO STANDARD SACRAMENTO STANDARD PLAN STANDARD 90%/$15 - POS SANTA BARBARA STANDARD SAN MATEO STANDARD PLAN STANISLAUS STANDARD PLAN SANTA CRUZ STANDARD PLAN STANDARD 90%/$15 POS COBRA PBGH 15 PLAN CBR BOEING BNA HRLY ERET STANDARD $15/250 MFP PLAN KEC S JAQUN CG GR07 KEC S JAQUN CGII GR07 KEC S JAQUN CGEH GR07 SJHS 100/80/50 MFP 196 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit S2M S2P S2R S2S S2T S2Y S2Z S32 S3A S3B S3C S3D S3E S3F S3G S3H S3J S3M S3N S3P S3Q S3X S3Y S3Z S42 S48 S4A S4B S4C S4D S4E S4F S4G S4J S4L S4M S4P S4X S4Y S58 S5A S5B S5C S5D S5E S5F S5G S5H S5J S5K Plan / Benefit Description ST MARY MFP 100/80/50 $15 POS PITNEY BOWES SV 15/200A SKYWEST 07 SV 15/200A SKYWEST 07 CB SV 15/200A SKYWEST 07 AB $15 POS PITNEY BOWES COBRA STANDARD $15/250 MFP CBRA KEC 1 S BRDO LO CG GR07 SANTA CLARA PLUS PLAN BOEING BNA HRLY ERET COBRA SAFEWAY 2000 SAN DIEGO - I PLUS PLAN SAN BERNARDINO PLUS PLAN SAN FRANCISCO PLUS PLAN SAN DIEGO - III PLUS PLAN KEC S JAQUN EP CG GR07 SJHS 100/80/50 MFP COBRA SACRAMENTO PLUS PLAN KEC S JAQUN EP CGII GR07 PITNEY BOWES ENHANCED POS KEC S JAQUN EP CGEH GR07 SH RETIREE STD 3 PITNEY BOWES ENHAN POS CBR SAFEWAY 2000 CBRA KEC 1 S BRDO LO CGII GR07 KEC 1 S BRDO DX CG GR07 SANTA CLARA STD W/OPT DNTL BSS HOURLY ACTIVES SV 10/100% 06 SAN DIEGO-I STD W/OPT DDS S BERNARDINO STD W/OPT DDS SAN FRANCISCO STD. W/DENTL S DIEGO III STD W/OPT DDS ST JOSEPH MFP $5/100% SV 10/100% 06 CB SACRAMENTO STD W/OPT DDS NORDSTROM POS PLAN SV 10/100% 06 AB NORDSTROM POS PLAN CBRA KEC 1 S BRDO DX CGII GR07 SANTA CLARA STD W/HI DENTL BSS HOURLY ACTIVES COBRA $15 HMO 2000 SER SAN DIEGO-I STD. W/HI DENT SAN BERN STANDARD W/HI DNT SAN FRANCISCO STD W/HI DEN STD $5 PLAN GRP RETIREE MCC SAN MATEO HIGH SH07 SV 15/200A SKYWEST AB KEC S JAQUN PP CG GR07 197 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit S5L S5M S5N S5P S5Q S5R S5W S5X S5Z S62 S66 S67 S68 S69 S6A S6B S6C S6D S6E S6F S6G S6H S6J S6L S6M S6N S6P S6Q S6R S6Y S6Z S7A S7B S7C S7D S7E S7F S7G S7H S7J S7M S7P S7Q S7R S7S S7T S7U S7W S7X S7Y Plan / Benefit Description MCC SAN MATEO LOW SH07 KEC S JAQUN PP CGII GR07 MC COMP SAN MATEO SH07 KEC S JAQUN PP CGEH GR07 KEC 1 S DEGO HI CG GR07 KEC 1 S DEGO H-P CG GR07 SH RETIREE STD 5 SH RETIREE STD 5 $15 HMO 2000 SER CBRA KEC 1 S BRDO LO CGEH GR07 KEC 1 S BRDO CG GR07 KEC 1 S BRDO CGII GR07 KEC 1 S BRDO DX CGEH GR07 KEC 1 S BRDO CGEH GR07 SANTA CLARA PLUS W/OPT DNT BSS HOURLY ERET HMO STD $15/100 MFP SAN DIEGO-I PLUS W/OPT DDS SAN BERN PLUS W/OPT DDS SAN FRANCISCO PLUS W/DENTL S DIEGO III PLUS W/OPT DDS MCC ESS S MATEO HIGH SH07 ST JOSEPH MFP $5/100% CBRA MCC ESS S MATEO LOW SH07 SACRAMENTO PLUS W/OPT DDS MC COMP ESS SAN MATEO SH07 ELGAR 100/80/70 KEC 1 S DEGO HI CGII GR07 KEC 1 S DEGO H-P CGII GR07 ELGAR 100/80/70 COBRA HMO STD $15/100 MFP COBRA SANTA CLARA PLUS W/HI DNTL BSS HOURLY ERET COBRA COLA 2001 HMO $15/$250 SAN DIEGO-I PLUS W/HI DNTL SAN BERNARDINO PLS-HI DNTL SAN FRANCISCO PLUS-HI DNTL SAN DIEGOIII PLUS W/HI DDS SH RETIREE STD 7 ST JOSEPH MFP $5/100% AB ST MARY MFP 100/80/50 CBR ELGAR 100/80/70 KEC 1 S DEGO HI CGEH GR07 KEC 1 S DEGO H-P CGEH GR07 KEC 1 S BRDO HI CG GR07 KEC 1 S BRDO HI CGII GR07 KEC 1 S BRDO HI CGEH GR07 KEC 1 S DEGO PL CG GR07 SH RETIREE STD 7 ELGAR 100/80/70 - COBRA 198 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit S7Z S86 S87 S89 S8A S8C S8D S8E S8G S8J S8N S8P S8R S8V S8W S8X S8Y S8Z S96 S97 S99 S9E S9F S9G S9J S9K S9N S9P S9W S9X S9Z SA1 SA2 SA3 SA4 SA5 SA6 SA7 SA8 SA9 SAA SAB SAC SAD SAE SAF SAG SAH SAI SAJ Plan / Benefit Description COLA 2001 HMO$15/$250 CBR MCC S LUIS OBPO PP-PL SH07 MCC S LUIS OBPO EP-PL SH07 MCC S LUIS OBPO PLUS SH07 SV 15-30/100% 06 STD 15 MFP $50ER SV 15-30/100% 06 CB MCC S LUIS OBPO EP SH07 STD $10 GRP RETIREE STD 15 MFP $50ER AB MC COMP SAN LUIS OBPO SH07 MCC S LUIS OBPO PP SH07 KEC S JAQUN DX CG GR07 KEC S JAQUN DX CGII GR07 KEC 1 S DEGO PL CGII GR07 SV 15-30/100% 06 AB KEC S JAQUN DX CGEH GR07 STD 15 MFP $50ER COBRA MCC ESS SL OBPO PP-PL SH07 MCC ESS SL OBPO EP-PL SH07 MCC ESS SL OBPO PLUS SH07 MCC ESS SL OBPO EP SH07 SP 10/100% PBGH 06 STD $15 GRP RETIREE SV 10/100% ST ANTHONY AB SP 10/100% PBGH 06 CB MC COMP ESS SL OBPO SH07 MCC ESS SL OBPO PP SH07 KEC 1 S DEGO PL CGEH GR07 SP 10/100% PBGH 06 AB AB1401 $15 HMO 2000 SER SH SACRAM BASIC MED W/ DEN SH SACRAMENTO STD W/ HI DE SACRAM PT B BAS MED W/ DEN SACRAMENTO PT B W/ HI DEN SH SACRAMENTO PLUS MED SACRAMENTO PLUS W/ HI DEN SH SACRAMENTO PART B PLUS SACRAMENTO PT B PL W/ HI D SV 10/100% ST ANTHONY CB DUMMY SR PLAN PART B ONLY SO CAL SV $20/100% SV $20/100% CB END SACRAM BASIC W/ NO DEN SP 10/100A SDSU 06 SR PLAN PART B SO CA GOLD SV $20/80% SV 15-30/100% SAIC SV $20/80% CB 199 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SAK SAL SAM SAN SAP SAQ SAR SAS SAT SAU SAW SAX SAY SAZ SB3 SB4 SB5 SB6 SB8 SB9 SBA SBB SBC SBD SBE SBH SBJ SBL SBM SBN SBP SBS SBW SBZ SC1 SC2 SC3 SC4 SC5 SC6 SC7 SC8 SCA SCB SCC SCD SCE SCF SCG SCH Plan / Benefit Description SP 10/100A SDSU 06 CB DUMMY SV $20/100% AB SR PLAN PART B SO CA NO DN SO.CAL.BASIC CHOICE PLAN SP 15/250A SDSU 08 SV 10/100% ST ANTHONY SR PLAN PART B SO CA SILVE KEENAN COMP 1 S BRDO GR07 KEC 1 S BRDO HIGH GR07 KEC 1 S BRDO LOW GR07 SP 10/100A SDSU 06 AB KEC 1 S BRDO DELUXE GR07 SV 15-30/100% SAIC CB SH RETIREE STD 3 BAYER CORP $15/$150A SH RETIREE STD 5 BAYER CORP $15/$150A COBRA SEC HORIZ. B-ONLY SD&VENT. SEC HORIZ. B-ONLY PLAN PART B ONLY-SANTA BARBARA SH BASIC PLAN-SANTA BARBAR SV 25/500A SBC COMM SOUTHERN BASIC DENTAL SV 20/100% SCL 06 SV 20/100% SCL 06 CB SR. OPERATIONS $15/$30 AB SV 20/100% SCL 06 AB SR PLAN MARIN PART B KEENAN COMP S BARBARA GR07 SO.CAL.PRT B ONLY-CHOICE SR PLAN SOLANO/SONOMA PT B 20 SC DRUG NON-AARP GR08 SV 25/500A SBC COMM CB SH SANTA CLARA STD MED SANTA CLARA STD W/ HI DEN SANTA CLARA PART B STD MED SANTA CLARA PT B W/ HI DEN SH SANTA CLARA PLUS MED SANTA CLARA PLUS W/ HI DEN SANTA CLARA PT B PLUS MED S CLARA PT B PL W/ HI DEN SH BSC ALAMEDA PART B ONLY SH BASIC-SANTA CLARA B ONL SH-BASIC PLAN-SAN CLARA CO SO.CALIF.DRUG CUSTOM RX SO. CAL. EDISON RETIREE-COUNTY OF FRESNO SV 10/100 SO CAL GAS SP 15/250A SCEET 06 200 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SCJ SCK SCL SCM SCP SCQ SCR SCS SCT SCU SCV SCW SCX SCY SCZ SD1 SD2 SD3 SD4 SD5 SD6 SD7 SD8 SDA SDB SDC SDD SDE SDF SDG SDH SDJ SDK SDL SDM SDN SDP SDQ SDR SDS SDU SDW SDX SDY SDZ SE1 SE2 SE3 SE4 SE5 Plan / Benefit Description SV 15-30/100% SAIC AB SV 20-35/250A SEN OP 06 SH BASIC-SANTA CLARA CO. 20/500A SO CA DRUG GR07 SH RETIREE SO CAL IBEW $15 IBEW GRP RET $10G/$15B/$25NF SV 10/100% SCDS 05 SV 10/100 SO CAL GAS CB RX RETIREE UFCW SC DRG MF SV 0/100% S CAL DRUG 06 SV 0/100% S CAL DRUG 06 CB SV 20-35/250A SEN OP 06 AB SV 0/100% S CAL DRUG 06 AB SV 20-35/250A SEN OP 06 CB SH SAN DIEGO STD MED SH SAN DIEGO STD W/ HI DEN SH SAN DIEGO PART B STD ME SAN DIEGO PT B W/ HI DEN SH SAN DIEGO PLUS MED SAN DIEGO PLUS W/ HI DEN SAN DIEGO PART B PLUS MED SAN DIEGO PT B PL W/ HI DE SH PART B ONLY-SAN DIEGO SAN DIEGO $10/100% COUNTY OF SAN DIEGO SV 25/250A SONY ELEC 07 END S DIEGO BASIC W/ NO DE SV 15/100% 1500D VEBA06 SP 10/100% CTY STAN 07 SP 15/250A SCEET 06 CB COUNTY OF SAN DIEGO AB SV 15/100% 1500D VEBA06 CB SVT 10-25/100% SD 07 SV $10/100% SD CNTY RET SV $10/100% SD CNTY RET CB SH-STD S.D. PHAN B ONLY SV 25/500A S CA DRUG 06 SV 15/100% 1500D VEBA06 AB SV 10/100% SCDS 05 CB SP 10/100A SDSU FNDTION SV 25/500A S CA DRUG 06 CB SAN DIEGO $10/100% COBRA SV 25/500A S CA DRUG 06 AB COUNTY OF SAN DIEGO COBRA SH SAN BERNARDINO STD MED S BERNARDINO STD W/ HI DEN S BERNARDINO PT B STD MED S BERNARDINO PT B W/ HI DE SH SAN BERNARDINO PLUS MED 201 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SE6 SE7 SE8 SE9 SEA SEB SEC SED SEE SEF SEG SEH SEJ SEK SEL SEM SEN SEO SEQ SER SES SET SEU SEV SEZ SF1 SF2 SF3 SF4 SF5 SF6 SF7 SF8 SFA SFB SFC SFD SFE SFF SFG SFH SFJ SFK SFL SFM SFN SFP SFQ SFR SFT Plan / Benefit Description S BERNARDINO PLUS W/ HI DE SAN BERNARDINO PT B PLUS S BERNARD B PLUS W/ HI DEN SV 10/100% SNDIEGO 06 AB SR PLUS SOLANO/SONOMA PT B SV 10/100% SNDIEGO 06 SEMPRA ENERGY $10 SV $10/100% SEMPRA END S BERN BASIC W/ NO DEN SV 10/100% SNDIEGO 06 CB SP 10/100% SCCS 07 SP 15/250A SCEET 06 AB SV 30/500A SEARS AB SV 15/200A SUREWEST 07 SVT 10-25/100% SD 07 CB SV $10/100% SEMPRA CB SV 10/100A CCSF 07 SV 15/30 100% SEN OP SP 10/100% SN LRNZO 07 CB SUPP ELIGIBILITY RIDER SP 10/100% SCCS 07 CB SV 10/100A SJHS 07 SP 10/100% SCCS 07 AB S. DIEGO ENHANCED VALUE SEMPRA ENGERY $10 - COBRA SH SAN FRANCISCO STD MED SAN FRANCISCO STD W/ HI DE SAN FRANCISCO PT B STD MED SAN FRAN PT B W/ HI DEN SH SAN FRANCISCO PLUS MED SAN FRAN PLUS W/ HI DEN SAN FRANCISCO PART B PLUS SAN FRAN PT B PL W/ HI DEN SH SAN FRAN PART B ONLY SV 5/100% SJHS 07 SPLIT FAMILY COVERAGE $10/$30/$60 SF END S FRAN BASIC W/ NO DEN SV 15/100% SEES 06 SV 15/100% SEES 06 CB SV 15/100% SEES 06 AB SV $15/100% AB SV 10/100% SCBAKERY 06 SVT 10-25/100% SD 07 AB SV $15/100% SV 10/100A CCSF 07 CB SV $15/100% CB SV 15/100% 06 SV 15/100% 06 CB SV 10/100A SJHS 07 CB 202 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SFX SG1 SG2 SG3 SG4 SG5 SG6 SG7 SG8 SGA SGB SGD SGE SGF SGG SGH SGJ SGK SGM SGN SGP SGQ SGR SGS SGT SGU SGV SGX SH1 SH2 SH3 SH4 SH5 SH6 SH7 SHA SHB SHC SHD SHE SHG SHH SHJ SHL SHM SHO SHP SHQ SHU SHV Plan / Benefit Description SPLIT FAMILIY ENROLLMENT SH SANTA BARBARA STD MED SANTA BARBARA STD W/ HI DE SANTA BARBARA PART B STD M RESERVED SAN DIEGO-III STD W/HI DDS SANTA BARB PLUS W/ HI DEN SANTA BARB PT B PLUS MED SANTA BARB PT B PL W/ HI D SR PLAN NCA SAC/EL DO PT B SV 5/100% SJHS 07 CB SV 15/100% SCEET 06 SV 0/100% SEIU 07 SV 15/100% SCEET 06 CB SV 15/100% SCEET 06 AB SV 10/100% SCFCHW 06 SV 10/100 SO CAL GAS AB SV 15/200A SUREWEST 07 CB GM $15 GRP RET SLRY SV 10/100A CCSF 07 AB SP10/200A SCSVEBA 06 SP 10/100% SN LRNZO 07 AB SV 0/100% SEIU 07 CB SP10/200A SCSVEBA 06 CB SV 10/100A SJHS 07 AB SV 0/100% SEIU 07 AB SP10/200A SCSVEBA 06 AB SH RETIREE STD 15 RETIREE $1 OV SH RETIREE STNDRD 2 SH STD 3 SH STD 4 SH STD 5 NO.CALIF.STANDARD 6 PLAN $7 CLOSED RX-RETIREE SV 20-40/500A+10% SBC06 HI-OP CHOICE PRT B ONLY SO SECURE HORIZONS B ONLY HI SECURE HORIZ. B ONLY PLAN SV 20-40/500A+10% SBC06 CB SH RETIREE STD 15 SECURE HORIZONS B ONLY PL UBS FINANCIAL SERV $20 AB SECURE HORIZONS PLAN RETIREE $10 OV SH PREFERRED $0 ER SH PREFERRED SP 15/100A SCEET 07 UFCW RETIREE $5 OV 203 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SHX SI3 SIJ SJ1 SJ2 SJ3 SJ4 SJ5 SJ6 SJ7 SJ8 SJ9 SJA SJB SJC SJD SJF SJH SJJ SJK SJL SJM SJO SJP SJQ SJR SJS SJT SJU SJV SJW SJX SJY SJZ SK1 SK2 SK3 SK4 SK5 SK6 SK7 SK8 SKA SKB SKD SKE SKF SKG SKH SKJ Plan / Benefit Description SV 20-40/500A+10% SBC06 AB SH SAN DIEGO MEDI-MEDI PLN SONY ELCTRNICS 20/100A AB SH SAN JOAQUIN STD MED SAN JOAQUIN STD W/ HI DEN SAN JOAQUIN PART B STD MED SAN JOAQUIN PT B W/ HI DEN SH SAN JOAQUIN PLUS MED SAN JOAQUIN PLUS W/ HI DEN SH SAN JOAQUIN PART B PLUS SAN JOAQUIN B PL W/ HI DEN SV 10 SJHS MFP 06 AB SAN JOAQUIN BASIC PLAN SAN JOAQUIN-PART B ONLY SV 20-30/250A SR OPS 06 SP 10/100% NTRDAME 06 SP 10/100% NTRDAME 06 CB SP 15 SJHS MFP 06 SV $20/80% AB SP 10/100% NTRDAME 06 AB SVA 10/100% SCSVEBA 06 ENTERED IN ERROR-SEE OR-43 KEC S JAQUN DELUXE GR07 SV 10 SJHS MFP 06 SP 15/100A SCEET 07 CB SVA 10/100% SCSVEBA 06 CB KEENAN COMP S JAQUN GR07 SVA 10/100% SCSVEBA 06 AB KEC S JAQUN EP GR07 SV 5/100% SCRUZMF 07 KEC S JAQUN PP GR07 SP 15 SJHS MFP 06 AB SV 10 SJHS MFP 06 CB SP 15 SJHS MFP 06 CB SH SANTA CRUZ STD MED SANTA CRUZ STD W/ HI DEN SANTA CRUZ PART B STD MED SANTA CRUZ PT B W/ HI DEN SH SANTA CRUZ PLUS MED SANTA CRUZ PLUS W/ HI DEN SANTA CRUZ PART B PLUS MED SANTA CRUZ PT B PL W/ HI D SH PART B ONLY - KERN CO. SV 15/200A SKYWEST 06 SP 10/100% SCEET 06 SH BASIC PLAN - KERN CO. SP 10/100% SCEET 06 CB SP 10/100% SCEET 06 AB SV 10/100% SCBAKERY 06 CB SV $10/100% SEMPRA AB 204 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SKK SKP SKQ SKR SKV SKX SKZ SL1 SL2 SL3 SL4 SL5 SL6 SL7 SL8 SLA SLB SLC SLD SLE SLF SLG SLH SLJ SLK SLL SLM SLN SLP SLS SLU SLV SLX SM1 SM2 SM3 SM4 SM5 SM6 SM7 SM8 SM9 SMA SMB SMC SMD SMJ SMM SMP SMS Plan / Benefit Description SV 10/100% SCBAKERY 06 AB SP 10/100% SGVMC 07 SP 15/100A SCEET 07 AB KEENAN COMP SAN FRAN GR07 SV 5/100% SCRUZMF 07 CB SV 15/200A SKYWEST 06 AB SV 15/200A SKYWEST 06 CB SH SAN LUIS OBISPO STD MED SH SLO STD MED W/ HI DEN SH SLO PART B STD MED SH SLO PT B STD W/ HI DEN SH SAN LUIS OBISPO PLUS ME SH SLO PLUS MED W/ HI DEN SH SLO PART B PLUS MED SLO PART B PLUS W/ HI DEN SH STANDARD-RX COUNTIES SH STD-RX CO. PHAN B ONLY SAN LUIS OBISPO CLASSIC I SV 25/250A SONY ELEC 07 CB S.L. OBSPO CLSC I W/EPODDS RX SLF SOLUTIONS SP 10/100% CTY STAN 07 CB SP 10/100% SN LRNZO 07 SV 10-25/250A SARES AB SV 25/250A SONY ELEC 06 SV 25/250A SONY ELEC 06 CB SH RETIREE LOCKHEED MARTIN KEENAN COMP SL OBSPO GR07 SH STD - RX COUNTIES PHAN SH BSC PLAN STANISLAUS S.L. OBSPO CLSC I W/ODPDDS SV 5/100% SCRUZMF 07 AB SV 25/250A SONY ELEC 06 AB SH SAN MATEO STD MED SH SAN MATEO STD W/ HI DEN SAN MATEO PART B STD MED SAN MATEO PT B W/ HI DEN SH SAN MATEO PLUS MED SAN MATEO PLUS W/ HI DEN SAN MATEO PART B PLUS MED SAN MATEO PT B PL W/ HI DE NON-STD BASIC 10 PLAN AB SAN MATEO-BASIC PLAN SAN MATEO-PART B ONLY SR PLAN MARIN SV 20/250A SPHERION 05 ST MARY MFP 100/80/50 AB SR PLUS MARIN PART B NON-STD BASIC 10 PLAN SV 20/250A SPHERION 05 CB 205 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SMX SMZ SN1 SN2 SN3 SN4 SN5 SN6 SN7 SN8 SNA SNB SNC SND SNE SNG SNJ SNK SNL SNP SNX SNY SO1 SO2 SO3 SO4 SO5 SO6 SO7 SO8 SOA SOB SOI SOJ SOQ SOU SOV SOW SOY SOZ SP1 SP2 SP3 SP4 SP5 SP6 SP7 SP8 SPA SPB Plan / Benefit Description SV 20/250A SPHERION 05 AB NON-STD BSC 10 PLAN COBRA SH SONOMA STD MED SH SONOMA STD MED W/ HI DE SH SONOMA PART B STD MED SONOMA PT B STD W/ HI DEN SH SONOMA PLUS MED SH SONOMA PLUS W/ HI DEN SH SONOMA PART B PLUS MED SONOMA PT B PLUS W/ HI DEN SR PLAN NO CAL -PART B SR PLAN -NO CAL SH STANDARD $10 100/80/60 PLAN SV 20/100A SONY SR PLAN NO CAL SACRA/EL DO SV 20/100A SONY AB SV 15/200A SUREWEST 07 AB KEENAN COMP SONOMA GR07 SH RETIREE PREFERRED SH RETIREE STD 10 100/80/60 PLAN COBRA SH SOLANO STD MED SOLANO STD MED W/ HI DEN SH SOLANO PART B STD MED SOLANO PT B STD W/ HI DEN SH SOLANO PLUS MED SOLANO PLUS MED W/ HI DEN SH SOLANO PART B PLUS MED SOLANO PT B PLUS W/ HI DEN SH BASIC PLAN SONOMA CO SH BASIC SONOMA CO B ONLY ARP MCC SLO EP-PL SH08 SV 15/30 100% SEN OP AB ARP MCC SLO PP-PL SH08 ARP MCC SLO PP SH08 ARP MCC SLO PLUS SH08 ARP MCC SLO SH08 ARP MCC SLO EP SH08 SV 15/30 100% SEN OP CB SUPPLEMENTAL LIFE BENE CALPERS CUSTOM PLAN SH RETIREE STD 3 HEWLETT PACKARD $15/$300 SH RETIREE STD 5 HEWLETT PACKARD 15/300 CBR UBS FINANCIAL SERV $20 UBS FINANCIAL SERV $20 COB SO.CAL.POS-BASIC PLAN SENIOR PLAN - SO CAL 206 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SPC SPE SPF SPG SPH SPJ SPK SPL SPM SPN SPO SPP SPQ SPR SPS SPX SPZ SQA SQB SQC SQD SQE SQF SQG SQH SQJ SQK SQL SQM SQN SQP SQT SQU SQW SQX SQY SQZ SR1 SR2 SR3 SR4 SR5 SR6 SR7 SR8 SR9 SRA SRB SRC SRD Plan / Benefit Description PBGH $15/100% NON STD PLAN PERS CUSTOM PLAN SP 15/200A SCSVEBA 06 SR PLAN SO CAL W/GOLD DENT SV 10/100% SCFCHW 06 CB HEWLETT PACKARD 15/300 AB SP 15/200A SCSVEBA 06 CB SP 20/100% CTY STAN 08 SR PLUS MARIN SR PLAN SO CAL NO DENTAL SECURE PREMIUM OFFSET SR PLUS SO CAL GOLD DENTAL SP 15/200A SCSVEBA 06 AB SR PREMIER SR PLAN SO CAL W/SILVER DE SR PLUS SO CAL PART B ONLY PBGH $15/100% NON STD CBRA SP 10/200A SCSVEBA 06 SPA 10/200A SCSVEBA 06 PBGH $15/100% NON STD SP 10/100% SCEET 06 END S CLARA BASIC W/ NO DE SP 10/100% SCEET 06 CB SP 10/100% SCEET 06 AB SP 10/200A SCSVEBA 06 CB SP 10/100% SND 05 AB SPA 10/200A SCSVEBA 06 CB SP 10/200A SCSVEBA 06 AB SPA 10/200A SCSVEBA 06 AB SV 20-35/100A STAN UV 08 SP 10/100% SGVMC 07 CB KEC 1 S DEGO HI GR07 ARP MCC S FRAN PP SH08 ARP MCC S FRAN SH08 SV 15/100% 06 AB ARP MCC S FRAN EP SH08 PBGH $15/100% NON STD COBR SEC HORIZ-RETIREE GROUP SEC HORIZ-RETIREE SD/VENT. SECURE HORIZ. TELEDYNE PLN SEARS ROEBUCK 30/500 SEARS ROEBUCK 30/500 COBRA SR. OPERATIONS $15/$30 SR. OPERATIONS $15/$30 CBR RETA TRUST $15/$250A RETA TRUST $15/$250A COBRA SR PREMIER PART B SR PLUS NO CA PART B SV 10/100% SEMPRA 06 SV 30/500A SEARS 06 207 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SRE SRF SRG SRJ SRK SRL SRM SRN SRO SRP SRQ SRR SRS SRT SRV SRX SRY SRZ SS2 SS3 SS4 SS5 SS7 SS8 SS9 SSA SSB SSC SSD SSF SSG SSH SSJ SSK SSL SSN SSP SSQ SSR SSS SSV SSX ST0 ST1 ST8 ST9 STA STB STC STD Plan / Benefit Description SV 30/500A SEARS SV 30/500A SEARS CB SVT 10-25/100% NONSD 07 RETA TRUST $15/$250A AB SV 10-25/250A SARES SV 10-25/250A SARES CB SV 20-35/250A SEN OP 08 SV 20-35/100A STAN UV 08CB POS SUPPLEMENTAL BENEFIT SR PLUS NO CA SP 15/250A SDSU 08 CB SV 20-40/250A SARES 06 SR PLUS SOLANO/SONOMA KEC 1 S DEGO HI-PL GR07 SV 30/500A SEARS 06 AB SV 10/100% SEMPRA 06 AB SV 30/500A SEARS 06 CB SV 10/100% SEMPRA 06 CB SONY ELCTRNICS 20/100A SH RETIREE STD 3 SONY ELCTRNICS 20/100A CBR SH RETIREE STD 5 SH RETIREE STD 7 SECURE HORZ. SD/VENTURA SECURE HORIZONS-STANDARD SH PART B ONLY-RX COUNTIES SECURE HORIZONS B-ONLY SEC HORIZ. B-ONLY SD&VENT. SH BASIC PLAN-SAN DIEGO SH BASIC PLAN- SAN FRAN CO SH RETIREE STD 15 SV 10/100% SCFCHW 06 AB SV $10/100% SD CNTY RET AB SH SILVER SNEAKERS SECURE HORIZONS-STANDARD SV 20-35/100A STAN UV 08AB SH-STD SAN DIEGO PHAN SP 10/100% SND 05 SLV SNEAK/FITNESS BEN GR06 SR PLAN SOLANO/SONOMA SECURE HORIZ. SD/VENTURA SH RETIREE STD 10 STANDARD PLAN INACTIVE STANDARD PLAN SV 15/250A RETA 05 SV 15/250A RETA 05 CB SH BASIC STANISLAUS SH PART B ONLY STANISLAUS SUTTER HEALTH $15 HMO RESERVED FOR PPO LIFE 208 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit STE STG STJ STN STP STQ STR STS STT STU STV STX STZ SU1 SU2 SU3 SU4 SU5 SU6 SU7 SU8 SUA SUB SUC SUD SUE SUF SUG SUH SUJ SUK SUL SUM SUN SUP SUQ SUR SUX SUY SUZ SV SV2 SV3 SV4 SV5 SV6 SV7 SVA SVB SVC Plan / Benefit Description KEENAN COMP STANSLAUS GR07 SP 10/100% CTY STAN 07 AB SV 15/250A RETA 05 AB SVA 15/500A SMW 07 SH RETIREE PREFERRED SP 10/100% SND 05 CB SP 15/200A SJHS 07 SVA 15/500A SMW 07 CB SP 15/200A SJHS 07 CB SVA 15/500A SMW 07 AB SP 15/200A SJHS 07 AB SH RETIREE STD 10 SUTTER HEALTH $15 HMO CBRA SH STANISLAUS STD MED STANISLAUS STD W/ HI DEN STANISLAUS PART B STD MED STANISLAUS PT B W/ HI DEN SH STANISLAUS PLUS MED STANISLAUS PLUS W/ HI DEN STANISLAUS PART B PLUS MED STANISLAUS PT B PL W/ HI D SP 15/100% SCEET 06 INDIV. STANIS B ONLY UC GRP RET 2002 CST HMO SP 10/100A SDSU 07 SP 10/100A SDSU 07 CB SP 15/100% SCEET 06 CB SP 10/100A SDSU 07 AB SP 15/100% SCEET 06 AB SP 10/100A SDSU FNDTION AB SV 25/250A SEES 07 SP 20/100% CTY STAN 08 CB SV 20-35/250A SEN OP 08 CB SV 10/100% SGVMC 07 SV 10/100% SEMPRA 06 SP 15/250A SDSU 08 AB SV 20-40/250A SARES 06 CB SV 10/100% SEMPRA 06 AB SP 10/100A SDSU FNDTION CB SV 10/100% SEMPRA 06 CB SV 20-30/250D PETCO 07 KEC 1 S DEGO LO CG GR07 SH STD 3 SAN DIEGO SH STD 4 SAN DIEGO SH STD 5 - SAN DIEGO KEC 1 S DEGO LO CGII GR07 KEC 1 S DEGO LO CGEH GR07 SH PART B ONLY-VENTURA SV 20-40/250A SARES 05 SP 15/200A SCSVEBA 06 209 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SVD SVE SVF SVG SVH SVJ SVK SVL SVM SVN SVP SVQ SVR SVS SVT SVU SVX SVZ SW2 SW3 SW4 SW5 SW7 SWA SWB SWC SWD SWE SWF SWG SWH SWJ SWL SWM SWN SWP SWQ SWT SWX SX2 SX6 SX9 SXA SXB SXC SXD SXE SXF SXG SXH Plan / Benefit Description SVA 5/100% SCSVEBA 06 SH BASIC PLAN-VENTURA SP 15/200A SCSVEBA 06 CB SVA 5/100% SCSVEBA 06 CB SPA 15/200A SCSVEBA 06 SV 10/100% SCDS 05 AB SP 15/200A SCSVEBA 06 AB SVA 5/100% SCSVEBA 06 AB SVA 20/250A SCSVEBA 06 SV 10/100% SGVMC 07 CB SH PREFERRED SAN DIEGO SPA 15/200A SCSVEBA 06 CB SVA 20/250A SCSVEBA 06 CB SPA 15/200A SCSVEBA 06 AB KEC 1 S DEGO LO GR07 SVA 20/250A SCSVEBA 06 AB SV 20-40/250A SARES 05 AB SV 20-40/250A SARES 05 CB WILLIAMS-SONOMA 20/100A WILLIAMS-SONOMA 20/100A CB SV 20/400A SMW 06 SV 20/400A SMW 06 CB SV 20/400A SMW 06 AB SKYWEST AIR $15/$200A SV 15/200A SKYWEST SV 15/100% ST MARYS 06 S DGO ENHNCD VALU W/OP DDS S DGO ENHNCD VALU W/EPODDS SV 15/100% ST MARYS 06 CB SVT 10-25/100% NONSD 07 CB S DGO ENHNCD VALU W/HI DDS WILLIAMS-SONOMA 20/100A AB SP 20/100% CTY STAN 08 AB SV 20-35/250A SEN OP 08 AB SV 10/100% SGVMC 07 AB SH RETIREE LADWP CUSTOM SV 20/200A+10% SRWST 08 KEC 1 S DEGO PLUS GR07 SV 15/100% ST MARYS 06 AB KEC 1 S DEGO CG GR07 KEC 1 S DEGO CGII GR07 KEC 1 S DEGO CGEH GR07 SV 5/100% SCEET 06 SV 20-35/250A SEN OP 07 SV 20-35/250A SEN OP 07 CB SV 20-35/250A SEN OP 07 AB SV 20-40/250A SARES 06 AB SV 5/100% SCEET 06 CB STD $10 PLAN GRP RETIREE SV 5/100% SCEET 06 AB 210 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SXJ SXK SXL SXM SXQ SXT SXV SY2 SY6 SY9 SYA SYB SYC SYD SYE SYF SYG SYH SYJ SYK SYL SYM SYP SYQ SYT SYU SYW SYX SYY SYZ SZ0 SZ1 SZ2 SZ3 SZ8 SZA SZB SZC SZD SZE SZF SZG SZH SZJ SZK SZL SZM SZP SZQ SZT Plan / Benefit Description SAN DIEGO $10/100% AB SV 25/250A SEES 07 CB SP 10/100% SCRUZ MF 07 SV 15/500A SMW 07 SV 20/200A+10% SRWST 08 CB KEENAN COMP 1 S DEGO GR07 STD $15 PLAN GRP RETIREE KEC 1 S DEGO L-P CG GR07 KEC 1 S DEGO L-P CGII GR07 KEC 1 S DEGO L-P CGEH GR07 SP 10/100% SCEET 06 SV 5/100% SJHS 07 AB NEW YORK COALITION PLAN 2A SV 25/250A SONY ELEC 07 AB SV 20/100A SONY CB SP 10/100% SCEET 06 CB SVT 10-25/100% NONSD 07 AB SP 10/100% SCEET 06 AB SJHS 100/80/50 MFP AB SV 25/250A SEES 07 AB SP 10/100% SCRUZ MF 07 CB SV 15/500A SMW 07 CB SP 10/100% SGVMC 07 AB SV 20/200A+10% SRWST 08 AB KEC 1 S DEGO LO-PL GR07 ARP MCC S JOAQUN PP SH08 ARP MCC S JOAQUN SH08 ARP MCC S JOAQUN DLX SH08 ARP MCC S JOAQUN EP SH08 N.Y. COALITION (2A) COBRA STANDARD 10 PLAN COBRA STANDARD PLAN (COBRA) CALPERS CUSTOM PLAN COBRA SH RETIREE STD 3 COBRA STD $10 GRP RETIREE CBRA SV 10/100% SCEET 06 SV 15/200A SKYWEST CB SV 10/100% C SN DGO 06 SV 10/100% C SN DGO 06 CB SP 10/100A SCSVEBA 06 SV 10/100% SCEET 06 CB SV 10/100% C SN DGO 06 AB SV 10/100% SCEET 06 AB SV 25/500A SBC COMM AB SP 10/100A SCSVEBA 06 SP 10/100% SCRUZ MF 07 AB SV 15/500A SMW 07 AB PERS RETIREE CUSTOM COBRA SP 10/100A SCSVEBA 06 CB SP 10/100A SCSVEBA 06 AB 211 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit SZW SZX SZZ T1C T1I T1P T1R T1S T1T T1U T1V T1W T1X T1Y T1Z T2I T2M T3I T3J T3M T4I T5I T6I TA2 TA3 TA6 TAA TAB TAC TAD TAE TAJ TAK TAW TAZ TBA TBB TBD TBE TBJ TBL TBN TBP TBZ TC2 TCA TCB TCC TCI TCJ Plan / Benefit Description SKYWEST AIR $15/$200A CBRA SP 10/100A SCSVEBA 06 AB SP 10/100A SCSVEBA 06 CB DUMMY PLAN-NOT IN USE INDIVIDUAL HMO 10 PLAN STANDARD 10/250 ELITE 100 CAL COBRA ELITE 100 ELITE 100 FED CBR EXTENDED ELITE 100 FED CBR DISABLED ELITE 100 CAL CBR EXTENDED ELITE 100 COBRA ELITE 100 CAL CBR DISABLED STANDARD 10/250 DUMMY PLAN-NOT IN USE G/I INDIVIDUAL HMO 10 PLAN SV TRI-CITY $10/100% CB INDIVIDUAL HMO 10 PLAN SV TRI-CITY $10/100% AB SP 10/100% TRICITY MED CB G/I INDIVIDUAL HMO 10 PLAN INDIVIDUAL PLAN 10 INDIVIDUAL PLAN 10 HIPAA SV 15/100% 05 AB SV 5/100% 05 AB $0/24 TRPS/YR NON-ERTRNS06 SP 10/100% TRI-CITY 06 SV 20-40/250D NCTILE 07 SV 15/100% 05 SV 15/100% 05 CB SV 20-35/90% TENET 07 SP 10/100% TRI-CITY 06 AB SV 5/100% 05 SV 5/100% 05 CB SP 10/100% TRI-CITY 06 CB SV 20-30/250A TRBUN 06 SV 20-40/250D NCTILE 07 CB MCC SACMETO DELUXE SH07 SVA 20-40/400A TMT 07 SV 20-30/250A TRBUN 06 AB MCC SACMETO LOW SH07 MC COMP SACMENTO SH07 MCC SACMETO PP SH07 SV 20-30/250A TRBUN 06 CB SV 10/100% 05 AB SV 5/100% TCUMTA 06 SV 10/100% 05 SV 10/100% 05 CB IND HMO 10 PLAN (COP) SP 10/100% TRICITY MED AB 212 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit TCK TCL TCM TCP TCS TCU TCX TCZ TD2 TDA TDC TDD TDJ TDZ TEA TEB TEC TEE TEK TEL TEP TEY TFA TFE TFF TFG TGK TH2 THA THB THR THS THW TJA TJC TJF TJJ TJK TJL TJM TJQ TJZ TK2 TKA TKB TKF TL3 TL5 TLA TM3 Plan / Benefit Description SV TRI-CITY $10/100% SV 5/100% TEAMSTERS 06 SP 10/100% TRICITY MED SV 5/100% TCUMTA 06 CB ADMIN-TOTAL COBRA SERVICES UC 2002 CUSTOM HMO SV 5/100% TCUMTA 06 AB UC 2002 CUSTOM HMO COBRA SV 0/100% 05 AB SV 10/100% TOYOTA 06 SV 0/100% 05 SV 0/100% 05 CB SV 10/100% TOYOTA 06 AB SV 10/100% TOYOTA 06 CB TELEPHONIC EAP-PILOT NO CA SV 20-40/250D NCTILE 07 AB KEENAN COMP SACMETO GR07 SV 20-35/90% TENET 07 CB SV 0/100% TEAMSTERS 06 SV 5/100% TEAMSTERS 06 CB 10/100 TAKECARE DISABLED 10/100 TAKECARE DISABLE CB SV 15/100% TOYOTA 08 SV 0/100% TEAMSTERS 06 SV 0/100% TEAMSTERS 06 CB SV 0/100% TEAMSTERS 06 AB SV 0/100% TEAMSTERS 06 CB SV 10/100% TMT 05 AB SV 10/100% TMT 05 SV 10/100% TMT 05 CB PAC ADVAN PLUS PLAN CCOBRA PAC ADVAN PLUS PLAN PAC ADVAN PLUS PLAN COBRA SV 15/100% TEAMSTERS 06 SV 15/100% HRT 06 SV 10/90% TENET 08 SV 15/100% HRT 06 AB SV 0/100% TEAMSTERS 06 AB SV 5/100% TEAMSTERS 06 AB SV 10/90% TENET 08 CB SV 10/90% TENET 08 AB SV 15/100% HRT 06 CB SV 15/100% TMT 05 AB SV 15/100% TMT 05 SV 15/100% TMT 05 CB SV 5/100% TRANS CU 07 SV 25/250A FRFLD 06 CB SV 25/250A FRFLD 06 AB SV 25/250A FRFLD 06 SP 10/100% FRFLD 06 CB 213 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit TM5 TMA TMC TME TMF TMG TMJ TMS TMT TMZ TNA TNB TNE TNF TO2 TO4 TO5 TO7 TOY TP1 TP2 TP7 TP8 TPA TPH TPJ TPL TPR TPT TQA TQC TQD TQE TQF TQL TQZ TRA TRB TRC TRE TRI TRJ TRZ TS2 TSA TSB TSC TSM TSZ TTA Plan / Benefit Description SP 10/100% FRFLD 06 AB SP 10/100% FRFLD 06 10/250 MFP PLAN SV 5/100% TBTRUST 06 SV 5/100% TBTRUST 06 CB SV 5/100% TBTRUST 06 AB SV 10/100% TOYOTA MS AB SV 10/100% TOYOTA MS SVA 15/100% TEAMSTRS 10/250 MFP PLAN COBRA SVA 15/100% TEAMSTRS 07 SV 15/100% TRI CITY 08 SV 20-35/90% TENET 07 AB SV 5/100% TRANS CU 07 CB SACRAMENTO II STD PLAN SACRAMENTO II PLUS PLAN SACRAMENTO II STD W/OP DDS SACTO II PLS PLN W/OP DDS SV 10/100% TOYOTA MS CB SH PLUS MED TRANSPORTATION TOWERS PERRIN $15 PLAN SH CA NON-ER TRANSPRTATION 16R/32ONE WAY NON-ER TRANS SV 20/100% TEAMSTERS 06 5-10/100% GR06 15-20/100A AARP GR08 15-20/100A GR06 PREMIUM REVERSAL 15-20/100A NON-AARP GR08 SVA 15/100% TEAMSTRS 07 CB CUSTOM HMO $10/$250 SV 0/100% TM TRUST 06 SVA 20-40/400A TMT 07 CB SV 0/100% TM TRUST 06 CB SV 0/100% TM TRUST 06 AB CUSTOM HMO $10/$250 COBRA SVA 15/100% TEAMSTRS 07 AB SV 20-30/250A TRIBUNE SV 20-30/250A TRIBUNE CB SVA 20-40/400A TMT 07 AB $15 100% TRIBUNE GR SV 20-30/250A TRIBUNE AB $15 100% TRIBUNE GR CB SV 20-40/400A TMT 05 AB SV 20-40/400A TMT 05 SV 20-40/400A TMT 05 CB STANDARD 10/250 MFP SACRAMENTO CLASSIC I STANDARD 10-250 MFP COBRA SV 10/100% TRI CITY 06 214 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit TTB TTC TTE TTG TTJ TTZ TU1 TU2 TU3 TU4 TU5 TU6 TU7 TU8 TUA TUB TUC TUE TUG TUH TUK TUL TUM TUP TUY TUZ TVA TVC TVE TVF TVG TVH TWA TWC TWD TWE TWF TWH TWJ TWK TWT TWZ TXA TXC TXJ TYA TYC TYD TYE TZA Plan / Benefit Description SV 15/100% TRI CITY 08 CB SP 10/100% TRI-CITY 07 SP 10/100% TRI-CITY 07 CB SP 10/100% TRI-CITY 07 AB SV 10/100% TRI CITY 06 AB SV 10/100% TRI CITY 06 CB SH TULARE STD MED SH TULARE STD MED W/ HI DE SH TULARE PART B STD MED SH TULARE PART B W/ HI DEN SH TULARE PLUS MED TULARE PLUS MED W/ HI DEN SH TULARE PART B PLUS MED TULARE PT B PLUS W/ HI DEN SV 25/90% TEAMSTERS 07 SV 15/100% TRI CITY 08 AB STANDARD 10/250 PLAN SV 10/100% TBTRUST 06 SV 10/100% TBTRUST 06 CB SV 10/100% TBTRUST 06 AB SV 30-45/80% TENET 08 SV 30-45/80% TENET 08 CB SV 30-45/80% TENET 08 AB 10/250 PLAN (UNISYS) 10/250 PLAN COBRA (UNISYS) STANDARD 10/250 PLAN COBRA SV 25/90% TEAMSTERS 07 CB INDIVIDUAL CONVERSION-FHP SV 15/100% TBTRUST 06 SV 5/100% TRANS CU 07 AB SV 15/100% TBTRUST 06 CB SV 15/100% TBTRUST 06 AB SV 25/90% TEAMSTERS 07 AB 10/250/50 FHP GUEST PLAN SACRAMENTO CLSC I W/OP DDS SACRAMENTO CLSC I W/EPODDS SP 15/100% TRI CITY 08 SP 15/100% TRI CITY 08 CB SVA 15/100% TEAMSTRS AB SP 15/100% TRI CITY 08 AB SVA 15/100% TEAMSTRS CB 10/250/50 FHP GUEST PLAN SV 25/500A THMX 06 SV 25/500A THMX 06 CB SV 25/500A THMX 06 AB SV 15/100% TOYOTA 08 CB SV 10/100% TENET 07 SV 10/100% TENET 07 CB SV 10/100% TENET 07 AB SV 15/100% TOYOTA 08 AB 215 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit TZL TZU TZW TZX U01 U02 U03 U04 U05 U06 U07 U08 U09 U10 U11 U12 U13 U14 U15 U16 U17 U18 U19 U1R U1S U1W U20 U21 U22 U23 U24 U25 U26 U27 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U3J U40 U41 U42 Plan / Benefit Description ARP MCC SACMTO LO SH08 ARP MCC SACMTO PP SH08 ARP MCC SACMTO SH08 ARP MCC SACMTO DLX SH08 USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSOTMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMAY PPO BASIC PLAN CAL COBRA BASIC PLAN BASIC PLAN COBRA USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO UFCW $25/$100 AB USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO 216 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit U43 U44 U45 U46 U47 U48 U49 U50 U51 U52 U53 U54 U55 U56 U57 U58 U59 U5J U60 UA2 UA3 UA4 UA5 UA7 UAA UAJ UAK UAZ UBA UBB UBC UBD UBJ UBS UC2 UC3 UCA UCB UCD UCF UCJ UCK UCM UCN UCP UCW UCX UCY UCZ UDA Plan / Benefit Description USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO UFCW $25/$250 AB USUAL & CUSTOMARY PPO SV $25/$500A SV $25/$500A CB SV $25/70% SV $25/70% CB 10/100A UNITED AL GR-07 SV 25/100% GGUSD 05 SV $25/70% AB SV $25/$500A AB SV 25/100% GGUSD 05 CB SVA 15-30/200A UHG 08 SV 25/70% 07 SV 25/70% 07 CB SV 25/70% 07 AB SV 20-30/100A UBS AB SV 20-30/100A UBS 10/250A UC GR05 SV 20-30/250A UBSFN 06 AB 15/250A UNIV CA GR06 SV 20-30/250A UBSFN 06 SP 35/150A NC UFCW 06 SP 35/150A NC UFCW 06 CB UNIVERSITY OF CALIF AB SP 35/150A NC UFCW 06 AB UNIVERSITY OF CALIF SV 10/250A UC 05 UTILIZATN CNTRL PRG CHRGS SP 35/150A NCUFCWW 05 UC SPECIAL ADMIN./SURVEY SV 20-30/250A UBSFN 06 CB UNIVERSITY OF CALIF COBRA SVA 15-30/200A UHG 08 CB 217 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit UDE UDJ UE3 UE5 UEA UEH UEJ UEL UEV UEW UEZ UF1 UF2 UF3 UF6 UFC UFE UFF UFJ UFL UFM UFO UFR UFS UFW UFX UFY UGB UGD UGJ UGZ UHB UHC UHJ UHZ UJF UJJ UKA UKF UKH UKJ UKL UKW UKZ ULA ULD ULF ULJ ULZ UM1 Plan / Benefit Description SV 20-40/300A USG 07 SV 25/100% GGUSD 05 AB ARP MCC 1 SD LO-PL SH08 ARP MCC 1 SD HI-PL SH08 SV 15-25/250A UNTD 06 ARP MCC 1 SD HI SH08 SV 15-25/250A UNTD 06 AB ARP MCC 1 SD LO SH08 ARP MCC 1 SD PLUS SH08 ARP MCC 1 SD SH08 SV 15-25/250A UNTD 06 CB UFCW RETIREE RX CODE UFCW RETIREE $25 UFCW CHIRO 25/12V GR04 SV 25/100A UFCW 06 UFCW SV 20-40/300A USG 07 CB SV 25/250A UFCW 06 SV 0/100% UFCW 06 AB SV 25/100A UFCW 06 CB SV 25/250A UFCW 06 CB UFCW SV 0/100% UFCW 06 CB SV 20-30/100A UBS CB SV 0/100% UFCW 06 SV 25/100A UFCW 06 AB SV 25/250A UFCW 06 AB SV 20/250A 06 SV 15-25/250A UA 07 SV 20/250A 06 AB SV 20/250A O6 CB SVA 20/250A 06 DUAL-OPTION - UHC 06 SVA 20/250A 06 AB SVA 20/250A 06 CB SVA 10/100% UFCW 07 SV 10/250A UC 05 AB SV 10/100% UT 06 SVA 10/100% UFCW 07 CB NOT USED SV 10/100% UT 06 AB NOT USED ARP MCC ES SD SH08 SV 10/100% UT 06 CB SV 10/100% UT 06 SV 15-25/250A UA 07 CB SVA 10/100% UFCW 07 AB SV 10/100% 06 AB SV 10/100% 06 CB UNITED METH/STAND-3-OPMH 218 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit UMA UMH UMJ UML UMW UMZ UNC UNJ UNZ UP1 UP2 UP3 UP4 UPA UPC UPJ UPP UPX UPY UPZ UQ3 UQ5 UQA UQH UQL UQV UQW URE USB USF USJ USX USY USZ UTC UUC UUP UUY UVC UW3 UW4 UW5 UW6 UWC UWD UWJ UWW UX3 UX5 UXH Plan / Benefit Description SV 15/100% UT 06 NOT USED SV 15/100% UT 06 AB NOT USED ARP MCC ES CE/SO SH08 SV 15/100% UT 06 CB SV 15/250A UC 06 SV 15/250A UC 06 AB SV 15/250A UC 06 CB UNION PACIFIC 20/250A UNION PACIFIC 20/250A CBRA SV $20/$250A UNION PAC SV $20/$250A UNION PAC CB SV 10/100% UTU-MAT 06 UFCW PODIATRY BENEFIT SV $20/$250A UNION PAC AB UNION PACIFIC $10 SV 10/100% UTU-MAT 06 AB SV 10/100% UTU-MAT 06 CB UNION PACIFIC $10 - COBRA ARP MCC 3 SD LO-PL SH08 ARP MCC 3 SD HI-PL SH08 SVA 15-30/200A UHG 08 AB ARP MCC 3 SD HI SH08 ARP MCC 3 SD LO SH08 ARP MCC 3 SD PLUS SH08 ARP MCC 3 SD SH08 SV 20-40/300A USG 07 AB SVA 20-40/300A USG 06 SV 20-40/300A USG 06 SVA 20-40/300A USG 06 AB SV 20-40/300A USG 06 AB SV 20-40/300A USG 06 CB SVA 20-40/300A USG 06 CB TAKING CHARGE OF YOU SV 20-40/200A UHG 08 15/250 PLAN COMM SYS WEST 15/250 PLAN COM SYS W CBRA SV 20-40/200A UHG 08 CB UFCW $25/$100 UFCW $25/$100 COBRA UFCW $25/$250 UFCW $25/$250 COBRA SV 20-40/200A UHG 08 AB SV 15-25/250A UA 07 AB SP 35/150A NCUFCWW 05 AB SP 35/150A NCUFCWW 05 CB ARP MCC PRE SD LO-PL SH08 ARP MCC PRE SD HI-PL SH08 ARP MCC PRE SD HI SH08 219 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit UXL UXV UXW UY3 UY5 UYH UYL UYV UYW UZ1 UZA UZC UZF UZS V00 V01 V02 V03 V05 V06 V0L V10 V15 V1J V1N V1P V1T V1Y V1Z V21 V23 V24 V25 V27 V2E V2F V2J V2M V2N V2R V2Z V30 V3E V3J V3M V3N V3R V3Z V4E V4J Plan / Benefit Description ARP MCC PRE SD LO SH08 ARP MCC PRE SD PLUS SH08 ARP MCC PRE SD SH08 ARP MCC VA SD LO-PL SH08 ARP MCC VA SD HI-PL SH08 ARP MCC VA SD HI SH08 ARP MCC VA SD LO SH08 ARP MCC VA SD PLUS SH08 ARP MMC VA SD SH08 UNITED METH/STAND-3-40OPMH SV 20/250A UHSD 06 SV 10/250A UC 05 CB SV 20/250A UHSD 06 CB SV 20/250A UHSD 06 AB VISION CARE $0 (VSP) RETIREE GOLD VISION RETIREE GOLD VISION VISION-SO.CAL.RETIREE GOLD VISION CARE $5 (VSP) DUMMY VISION CARE $0 VSP-LA CNTY $10 VSP-VALUECARE ROLLOVER VISION CARE $15 (VSP) STD 10 VALUE NETWORK AB STD 10 VALUE NETWORK 15/80 MFP POS-D. FREEMAN VENTURA STANDARD PLAN 15/80 MFP POS COBRA D. FRE STD 10 VALUE NETWORK COBRA RET.GOLD $0 EXAM MCD-A1325 RET.GOLD $5 TRW-EH790 RET.GOLD $5 CO-PAY VISION - THRIFTY/PAYLESS SC 20 ELIGIBILITY ONLY SVA $10/$20/$100D 25/70A TOWERS GR-VN06 VSP SVA $20/80% AB SVA $25/70% STD 10/20 VALUE NETWORK SVA $20/80% STD 10/20 VALUE NETWRK COB VISION CARE $30 (VSP) SVA $10/$20/$100D CB SVA $10/$20/$100D AB SVA $25/70% CB UB STD 10 VALUE NETWORK SVA $20/80% CB UB STD 10 VALUE NETWRK COB SVA $20/100% SVA $20/100% AB 220 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit V4M V4N V4R V4T V4Z V5E V5J V5M V5N V5R V5S V5T V5Z V6E V6J V6M V6N V6Z V7E V7G V7H V7J V7M V7N V7Z V8E V8J V8M V8N V8P V8Q V8R V8S V8T V8U V8V V8W V8X V8Z V9E V9J V9M VA4 VA6 VAJ VB6 VBA VBB VBC VBE Plan / Benefit Description SVA $15/$30/80% STD 10/20 VALUE SELECT SVA $20/$40/$250A VENTURA STANDARD W/OPT DNT STD 10/20 VALUE SELECT COB SVA $20/100% CB SVA $15/$30/80% AB SVA $15/$30/80% CB NON-STD 15 VALUE NETWORK SVA $20/$40/$250A CB $5/$100 ALLOW S GOLD VENTURA STANDARD W/HI DNTL NON-STD 15 VALUE NET-COBRA SVA $15/$250A SVA $15/$30/$250D AB SVA $15/$30/$250D VALUE NETWK $10-$20/80 VALUE NETWK $10-$20/80 CBR SVA $15/$250A CB 25/125A 2YRS GR-VN07 VSP 15/75A 2YRS GR-VN07 VSP SVA $15/$250A AB SVA $15/$30/$250D CB VALUE NETWK $15-$30/80 VALUE NETWK $15-$30/80 CBR SVA $10/100% SVA $25/$500A AB SVA $25/$500A VALUE NETWK $20-$40/$250A 0 REFRAC 1/V YR VN-GR08 5 REFRAC 1/V YR VN-GR08 10 REFRAC 1/V YR VN-GR08 15 REFRAC 1/V YR VN-GR08 20 REFRAC 1/V YR VN-GR08 25 REFRAC 1/V YR VN-GR08 30 REFRAC 1/V YR VN-GR08 35 REFRAC 1/V YR VN-GR08 40 REFRAC 1/V YR VN-GR08 VALUE NETWK 20-40/250A CBR SVA $10/100% CB SVA $10/100% AB SVA $25/$500A CB 30/70A 2YRS GR-VN07 5/100A 2 YRS SH-VN06 SVA 10-20/100D AB C25/$150A 2YRS VISION 06 SVA 20-40/50% 07 SV 15/150A VERIZON 08 VSP VISION $10 BOEING CUST 10/75A 2YRS GR-VN07 221 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit VBJ VBO VBP VBY VC2 VCA VCC VCD VCE VCH VCJ VCN VCS VCX VDA VDB VDE VDF VDG VDH VDJ VE3 VE4 VE5 VEA VEB VEC VED VEJ VEP VFI VFJ VFP VFQ VG6 VGA VGJ VGN VGP VGQ VH6 VHA VHJ VHM VHN VHO VHP VHS VI5 VI6 Plan / Benefit Description VALUE NETWK 20-40/250A AB VSP BOEING REP VISION $0 BOEING VISION $10 (VSP) 15/75A BOEING GR-VN07 VSP $5 VISION COUNTY LA 0/75A GR-VN07 PDV PHS VISION PLAN VENTURA CLASSIC I W/OP DDS VENTURA CLSC I W/EPO DDS SVA 20/250A C4H05 UB STD 10 VALUE NETWORK AB SVA 20/250A C4H05 CB VENTURA CLASSIC I SVA 20/250A C4H05 AB 15/70A GR-VN07 SV 15/150A VERIZON 08 CB SVA 10/100% 06 CB 15/125A 2YRS GR-VN07 SVA 20-40/50% SVA 20-40/50% CB SVA $10/100% AB SH STD 3 VENTURA/KERN SH STD 4 VENTURA/KERN SH STD 5 VENTURA/KERN SVA 20-40/50% 07 CB SV 15/150A VERIZON 08 AB KEENAN COMP VENTURA GR07 SVA 10/100% 06 SVA 10/100% 06 AB SH PREFERRED VENT./KERN FREEDOM PLAN 168 SVA 10-20/100A AB 0/75A 2YRS VN-GR08 0/125A 2YRS VN-GR08 25/75A VN-GR06 SVA 20-40/50% 07 AB SVA 20-40/50% AB SVA 10-20/100A 06 5/75A 2YRS VN-GR08 5/125A 2YRS VN-GR08 10/70A 2YRS VN06 VSP 15/75A 2YRS GR-VN06 SVA $25/70% AB HI-OPTION VISION $7 COPAY HI-OPTION VISION $15 COPAY HI-OPTION VISION $20 COPAY HI-OPTION VISION $10 COPAY HI-OPTION VISION $5 COPAY RETIREE GOLD VISION RETIREE GOLD VISION 222 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit VI7 VI8 VJA VJJ VJN VJQ VKA VKB VKE VKG VKJ VKP VL1 VL2 VL3 VL4 VL5 VLA VLB VLC VLD VLE VLJ VLK VLX VM0 VM1 VM2 VM3 VM4 VM5 VMA VMC VMD VME VMH VMJ VMQ VMR VMS VN1 VN2 VN3 VN4 VN5 VN8 VN9 VNA VNB VNC Plan / Benefit Description RETIREE GOLD VISION RETIREE GOLD VISION SVA 10-20/100A 07 SVA 15-30/80% AB SVA 10-20/100A 06 CB 10/75A 2YRS VN-GR08 SVA 10-20/100A 07 CB SV 15/100% VERIZON 07 SV 15/100% VERIZON 07 CB SV 15/100% VERIZON 07 AB SVA 10-20/80% AB 10/125A 2YRS VN-GR08 W FARGO VALUE NETWORK XEROX VALUE NETWORK LOCKHEED VALUE NETWORK PITNEY BOWES VALUE NETWORK SVA 20-30/100A LM 06 W FARGO VALUE NETWORK COBR XEROX VALUE NETWORK COBRA LOCKHEED VN - COBRA PITNEY BOWES VN COBRA 0/12V L3/ETI VN05 VSP XEROX VALUE NETWORK AB SVA 20-30/100A LM 06 CB SVA 20-30/100A LM 06 AB VISON MESC $0 COPAYMENT MESC VISION - PERS/MEDCARE MESC/COUNTY OF FRESNO RET MESC VISION-PERS MEDICARE MESC VISION - EYEWEAR ONLY $20/$20 MESC-GOLDEN EAGLE SVA 10-20/100A 07 AB SV 20/100A VERIZON 07 CB VENTURA MEDICAL W/OP DDS VENTURA MEDICAL W/EPO DDS VENTURA MEDICAL W/HIOP DDS SVA 20-40/250A AB 15/125A 2YRS VN-GR08 15-15/75A VN-GR08 VENTURA MEDICAL 5/125A VN-GR06 10/75A 2YRS GR-VN06 RESERVED SH VENTURA STD-II HI PLAN 20/75A VN-GR06 SH VENTURA STD-II W/OP DNT SH VENTURA STD-II W/HI DNT SVA 10-20/100D SVA 10-20/100D CB NON STANDARD $15/80% 223 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit VND VNE VNF VNG VNH VNJ VNK VNL VNM VNN VNQ VNZ VO4 VOC VOH VP1 VP6 VPA VPC VPD VPE VPF VPH VPJ VPL VPP VPX VQ3 VQ5 VQB VQC VQD VQF VQH VQJ VQK VQL VQP VQR VQV VQW VRB VRJ VRO VRP VRR VRS VS0 VS1 VS2 Plan / Benefit Description SVA $10/100% SVA $10/100% CB SVA 10-20/100A SVA 10-20/100A CB SVA 15-30/80% SVA 15-30/80% CB SVA 10-20/80% SVA 10-20/80% CB SVA 20-40/250A SVA 20-40/250A CB 20/75A 2YRS VN-GR08 NON STANDARD $15/80% COBRA RETIREE GOLD VISION VISION CARE $0 VSP-CNTY LA HI-OPTION VISION DUMMY ADVANCE WELLNESS SH-WL06 SVA 20/90% WELLS FARGO SVA 20/90% WELLS FARGO CB SP 10/100% VERTEX 06 RESERVED PFFS SP 10/100% VERTEX 06 CB VISION $10 VSP SVA 20/90% WELLS FARGO AB VISION VSP $15 20/125A 2YRS VN-GR08 SP 10/100% VERTEX 06 AB ARP MCC VNTRA LO-PL SH08 ARP MCC VNTRA HI-PL SH08 SV 20/100A VERIZON 08 15/130A 1YR DLX VN-SH08 30/70A 2YRS VN-SH08 0/130A 2 YRS VN-SH08 ARP MCC VNTRA HI SH08 5/100A 2YRS VN-SH08 0/75A 2YRS VN-SH08 ARP MCC VNTRA LO SH08 25/70A 2YRS VN-GR08 0/70A 2YRS VN-SH08 ARP MCC VNTRA PLUS SH08 ARP MCC VNTRA SH08 SV 20/100A VERIZON 08 CB SVA $20/$40/$250A AB SVA 15/250A ROSS CB VISION CARE $10 RNP (VSP) 10/75A GR-VN07 SVA 15/250A ROSS VISION $0 CO-PAY CUSTOM SR PLAN VISION SO.CAL SR PLUS VISION-SO.CAL 224 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit VS3 VS4 VS5 VS6 VS7 VS8 VS9 VSE VSF VSH VSJ VSK VSQ VSX VT1 VT2 VT3 VT4 VT5 VT6 VT7 VT8 VTA VTB VTE VTJ VTM VTO VTW VU4 VU6 VUA VUC VUT VVA VVJ VVP VVQ VWA VWC VWM VWP VX2 VXA VXC VXJ VYA VYF VYG VYH Plan / Benefit Description SR PLAN VISION - NO CAL SR PLUS VISION - NO CAL SR PREMIER VISION - NO CAL RG VISION CUSTOM RG PREMIER CUSTOM RETIREE GOLD VISION RETIREE GOLD VISION 0/75A 2YRS SH-VN07 0/130A 2 YRS SH-VN07 VENTURA CLSC I W/HIOP DDS SVA 15/250A ROSS AB 5/100A 2YRS SH-VN07 30/70A 2YRS SH-VN07 15/130A 1YR DLX SH-VN07 SH VENTURA STD MED SH VENTURA STD W/ HI DEN SH VENTURA PART B STD MED SH VENTURA PT B W/ HI DEN SH VENTURA PLUS MED VENTURA PLUS MED W/ HI DEN SH VENTURA PART B PLUS MED VENTURA PT B PLUS W/ HI DE SVA 15-30/80% 07 SV 20/100A VERIZON 08 AB END VENTURA BASIC W/ NO DE SVA 20-40/400A TEAMSTER AB SVA 20-40/400A TEAMSTER VISION ONLY SVA 20-40/400A TEAMSTER CB 15/130A 1YR DLX GR-VN07 15/75A 2YRS VN-GR06 SVA 15-30/80% 07 CB SV 20/100A VERIZON 07 AB 10/12V VN06 VSP SVA 15-30/80% 07 AB SVA 10-20/100A 06 AB 15/75A 2YRS VN-GR08 25/75A 2YRS VN-GR08 SVA 20-40/250A 07 SV 20/100A VERIZON 07 PDV VISION WAL MART 25/125A 2YRS VN-GR08 SVA $15-$30/$250A XEROX CB SVA 20-40/250A 07 CB SVA $15-$30/$250A XEROX SVA $15-$30/$250A XEROX AB SVA 20-40/250A 07 AB SVA $25/70% 07 SVA $25/70% 07 CB SVA $25/70% 07 AB 225 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit VYZ VZ2 VZ3 VZ4 VZ5 VZ6 VZ7 VZ8 VZ9 VZA VZF VZJ W1C W1D W1E W1F W1G W1I W1R W1S W1W W1Z W2C W2I W2J W2Z W3C W3D W3I W3J W3U W3Z W4C W4D W4I W4J W4Z W5C W5D W5I W5J W5Z W6D W6I W6J W7C W7D W7I W7J W7Z Plan / Benefit Description 10/125A 2YRS GR-VN07 SV 20/1500-DED SG06 CB SV 20/1500-DED SG06 AB SV 20/1500-DED SG06 CC SV 20/1500-DED SG06 CE SV 20/1500-DED SG06 CD SV 20/1500-DED SG06 FE SV 20/1500-DED SG06 FD SV 20/1500-DED SG06 US SV 20/1500-DED SG06 15/75A BOEING VN-GR08 0 BOEING VN-GR08 15/250 PLAN ELITE 15 FED CBR DISABLED ELITE 15 FED CBR EXTENDED ELITE 15 CAL CBR EXTENED ELITE 15 CAL CBR DISABLED INDIVIDUAL HMO 15 PLAN ELITE 15 PLAN CCOBRA ELITE 15 PLAN ELITE 15 PLAN COBRA 15/250 PLAN COBRA $15/$250 HMO 2000 SER INDIVIDUAL HMO 15 7/00 $15/$250 HMO 2000 SER AB $15/$250 HMO 2000 SER CBRA PBGH $15/$250 $50 ER HMO 15 PLAN G/I INDIVIDUAL HMO 15 7/00 HMO 15 PLAN AB HMO 15 PLAN USERRA PBGH $15/$250 $50 ER COBRA NON STANDARD 15/150 HMO 15 PLAN COBRA I PLAN HMO $35/30% MERLE NORMAN $15/250A AB NON STANDARD 15/150 CBRA $15/$100 HMO 2000 SER HMO 15 PLAN CAL COBRA INDIVIDUAL PLAN 15 $15/$100 HMO 2000 SER AB $15/$100 HMO 2000 SER CBRA HMO 15 FED CBR DISABLED INDIVIDUAL PLAN 15 HIPAA SV 15/250A AB BENEFIT ALLIANCE PLAN C HMO 15 FED CBR EXTENDED I PLAN $35/30% HIPPA SV 15/100A AB BENEFIT ALLIANCE PLAN C CB 226 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit W8D W8I W9D W9J WA7 WA8 WAA WAB WAC WAJ WAK WAL WAP WAX WB6 WBJ WC2 WC3 WC5 WC6 WC7 WC8 WCI WCJ WD1 WD2 WD3 WD4 WD5 WD6 WD7 WDJ WDU WE5 WE6 WE7 WE8 WEJ WEL WF2 WFA WFB WFC WFD WFE WFF WFG WFH WFJ WFK Plan / Benefit Description HMO 15 CAL CBR EXTENDED I PLAN $35/30% HIPPA H HMO 15 CAL CBR DISABLED SV 15/250A MERLE NORM AB SV $15/$250A SV $15/$250A CB SV $15/$30/$250D SV $15/$30/$250D CB SV 25/100A WACHOVIA 06 SV $15/$250A AB SV $15/$30/$250D AB SV 25/100A WACHOVIA 06 CB RESERVED WT ALT PROGRAMS SV 25/100A WACHOVIA 06 AB HLTH EDUC 12 SESSIONS 06 LOWE ENTERPRISE $20/$30 AB LOWE ENTERPRISE $20/$30 LOWE ENTERPRISE $20/$3 CBR SV 15/250A SV 15/250A CB SV 15/100A SV 15/100A CB IND HMO 15 PLAN (COP) SV $15-$30/80% AB SV $15-$30/250A SV $15-$30/250A CB SV $15-$30/250A CAL CB SV $15-$30/250A FED CB DIS SV $15-$30/250A FED CB EXT SV $15-$30/250A CAL CB EXT SV $15-$30/250A CAL CB DIS SV $15-$30/250A AB SV $15-$30/250A USERRA SV 15/250A 05 SV 15/250A 05 CB SV 15/100A 06 SV 15/100A 06 CB SV $15-$30/$250D AB WELLNESS PROGRAM SV 20/90% WLS FRGO 06 AB SV 20/90% WLS FRGO 07 SVA 20/90% WLS FRGO 06 SV 20/90% WLS FRGO 06 SV 20/90% WELLS FARGO SV 20/90% WELLS FARGO CB SVA 20/90% WLS FRGO 06 CB SV 20/90% WLS FRGO 06 CB SV 20/90% WLS FRGO 07 CB SV 20/90% WELLS FARGO AB SV 20/90% WLS FRGO 07 AB 227 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit WFL WFQ WFT WFX WGJ WHJ WHP WHR WHS WHT WHW WHX WHZ WIR WJJ WK1 WK2 WK3 WK4 WK5 WK6 WK7 WKC WKD WKE WKF WKU WLA WLC WLD WLE WLF WLG WLJ WLL WLZ WM2 WM3 WM4 WM5 WM6 WM7 WMC WMJ WMS WMZ WN1 WN2 WN3 WNC Plan / Benefit Description SVA 20/90% WLS FRGO 07 SVA 20/90% WLS FRGO 07 CB SVA 20/90% WLS FRGO 07 AB SVA 20/90% WLS FRGO 06 AB SV 15/250A 05 AB SV 15/100A 06 AB SV 3/100% WEYERHAEUSER STANDARD PLAN/HIPC CAL CBR STANDARD PLAN HIPC PAC ADVANTAGE STD PLAN STANDARD PLAN HIPC COBRA PAC ADVAN STD PLAN COBRA SV 3/100% WEYERHAEUSER CB PAC ADVAN STD PLAN CCOBRA SV 20/100A WM SONOMA 05 AB HMO 15 PLAN HMO 15 PLAN COBRA HMO 15 PLAN CCOBRA HMO 15 FED CBR DISABLED HMO 15 FED CBR EXTENDED HMO 15 CAL CBR EXTENDED HMO 15 CAL CBR DISABLED SV $15-$30/80% SV $15-$30/80% CB SV $15-$30/$250D SV $15-$30/$250D CB HMO 15 PLAN USERRA SV 20/100A WM SONOMA 05 CB $15/$250 PLAN COUNTY OF LA SV 3/100% WRHSR 06 SV 3/100% WRHSR 06 CB SV 0/100% WALGREEN 06 SV 3/100% WRHSR 06 AB SV 0/100% WALGREEN 06 AB SV 0/100% WALGREEN 06 CB $15/$250 COUNTY OF LA COBR MARRIOTT ADV 15-25/100A MARRIOTT ADV 15-25/100A CB MERLE NORMAN $15/250A MERLE NORMAN $15/250A CBRA SV 15/250A MERLE NORM SV 15/250A MERLE NORM CB $15/$250 COUNTY OF LA MARRIOTT ADV 15-25/100A AB SV 20/100A WM SONOMA 05 $15/$250 COUNTY OF LA CBRA SV 3/100% LADWP 06 SV 3/100% LADWP 06 CB SV 3/100% LADWP 06 AB N.Y. COALITION 15/500 228 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit WNZ WOC WOZ WPB WPC WPD WPJ WPP WPR WPS WPT WPX WPY WPZ WQC WQP WQR WQS WQT WQY WQZ WRA WRP WRR WRS WRT WRY WRZ WS2 WS3 WSA WSP WSY WSZ WV1 WVB WVG WVH WVJ WVZ WZ2 WZ3 WZ4 WZ5 WZ6 WZ7 WZ8 WZ9 WZA X00 Plan / Benefit Description N.Y.COALITION 15/500 COBRA 15/500 TAKECARE DISABLED 15/500 TAKECARE DIABLE CBR SV 3/100% WYRHSR 06 CREATED IN ERROR SV 3/100% WYRHSR 06 CB SV 3/100% WEYERHAEUSER AB PAINEWEBBER POS 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 SV 3/100% WYRHSR 06 AB PAINEWEBBER POS (COBRA) CREATED IN ERROR P DUMMY PLAN-NOT IN USE $15 POS MFP OPTION 6 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 $15 POS MFP OPTION 6 COBRA DUMMY PLAN-NOT IN USE HMO 15 RAYTHEON POS 15 RAYTHEON 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 POS 15 RAYTHEON HMO 15 RAYTHEON CBRA STATE FARM 25/250A STATE FARM 25/250A COBRA RAYTHEON 15 HMO EA RET RAYTHEON 15 POS EA RET RAYTHEON 15 POS EA RET CBR RAYTHEON 15 HMO EA RET CBR SV 20/100A WACHOVIA SV 25/100A WACHOV 07 SV 25/100A WACHOV 07 CB SV 25/100A WACHOV 07 AB SV 20/100A WACHOVIA AB SV 20/100A WACHOVIA CB SVA 35/600D SG06 CB SVA 35/600D SG06 AB SVA 35/600D SG06 CC SVA 35/600D SG06 CE SVA 35/600D SG06 CD SVA 35/600D SG06 FE SVA 35/600D SG06 FD SVA 35/600D SG06 US SVA 35/600D SG06 NO RX-CARVE OUT RXSOL 100I 229 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit X0A X1N X2N X50 XA0 XA1 XA2 XA3 XA4 XA5 XA6 XA7 XA8 XA9 XAA XAB XAC XAD XAE XAF XAG XAH XAI XAJ XAK XAL XAM XAN XAP XAQ XAR XAS XAT XAU XAV XAW XAX XAY XAZ XB0 XB1 XB2 XB3 XB4 XB5 XB6 XB7 XB8 XB9 XBA Plan / Benefit Description NORX-CO RXSO 100%I $10G/$25B $10G/$25B NO RX-CARVE OUT RX SOL 50I $0 $1 $2 $3 $4 $5 $6 $7 $8 $9 $10 $5G/$10B $5G/$5+30%B $10 $5/$7/70% $5G/$15B $10G/$15B $5 $5G/$10B $5 $5 $10 $5G/$10B $10 $5G/$10B $10G/$15B $5G/$25B $10G/$30B $15G/$35B $10 $5 $10G/$30B $10 $5G/$10B $5G/$20B $0 $1 $2 $3 $4 $5 $6 $7 $8 $9 $10 230 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit XBB XBC XBD XBE XBF XBG XBJ XBK XBL XBM XBN XBP XBR XBS XBZ XC1 XC2 XC3 XC5 XCA XCB XCC XCD XCE XCH XCJ XCM XCN XCO XCP XD4 XD5 XDA XDB XDC XE5 XEF XEL XEO XF3 XF5 XF6 XFA XFE XFF XG7 XGA XGB XGC XGD Plan / Benefit Description $5G/$10B $5G/$5+30%B $6G/$12B $2.50 SVA 15-30/250A XEROX 06 SVA 15-30/250A XEROX 06 CB $5 $5G/$10B $5 $10 $5G/$10B $10G/$20B $5G/$25B $10G/$30B $5G/$20B $5G/$10B $10 SV 35/600D 05 USERRA $5 $10 $10 $5G/$7B $3 INDEMNITY PHARMACY $5G/$10B SVA 15-30/250A XEROX 06 AB $4G/$7B CAREMARK $0 $0/90% $5G/$20B SV 35/600D 05 CAL CB $5G/$15B $5G/$10B $10G/$20B $5G/$10B $5 SVA 15-30/250A SG07 FD $5/$7/90% $0/80% $3 $5 SV 35/600D 05 FED CB DIS SVA 20-40/500D SG 07 FE CUSTOM RX FOOD EMP.BENEFIT SVA 15-30/250A SG07 FE SV 35/600D 05 FED CB EXT SVA 20-40/500D SG 07 CD SVA 15-30/250A XEROX 07 SVA 10-30/100% SG07 SVA 15-30/250A XEROX 07 CB 231 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit XGF XGG XGH XH8 XHA XIH XJ9 XJD XKE XKF XKG XKH XMA XMB XMI XMP XNG XQD XQG XRD XRG XSD XSG XTA XTE XUA XUE XVA XVC XVD XVE XXA XXB XXJ XXX XYE XYF XYG XZ1 XZ2 XZ3 XZ4 XZ5 XZ6 XZ7 XZ8 XZ9 XZA Y00 Y0A Plan / Benefit Description SVA 10-30/100% SG07 CB SVA 15-30/250A XEROX 07 AB SVA 10-30/100% SG07 AB SV 35/600D 05 CAL CB EXT SVA 20-40/500D SG 07 CE 0%G/20%B SV 35/600D 05 CAL CB DIS $10G/$15B SVA 15-30/250A SG07 SVA 15-30/250A SG07 CD SVA 10-30/100% SG07 US SVA 15-30/250A SG07 CE $10G/$15B $10 OR 50%/$100 DEDUCTIBLE $10G/$15B $10G/50%B $100 DED SVA 10-30/100% SG07 CC SVA 20-40/500D SG 07 US SVA 10-30/100% SG07 FD SVA 20-40/500D SG 07 CC SVA 10-30/100% SG07 FE SVA 20-40/500D SG 07 FD SVA 10-30/100% SG07 CD SV 20-40/250A XANTRX 08 SVA 15-30/250A SG07 CB SV 20-40/250A XANTRX 08 CB SVA 10-30/100% SG07 CE SV 20-40/250A XANTRX 08 AB SVA 15-30/250A SG07 CC SVA 15-30/250A SG07 US SVA 15-30/250A SG07 AB SV 35/600D 05 SV 35/600D 05 CB SV 35/600D 05 AB NO BENEFIT SVA 20-40/500D SG 07 SVA 20-40/500D SG 07 CB SVA 20-40/500D SG 07 AB BAXTER PLAN (COBRA) SVA 20/1500-DED SG06 CB SVA 20/1500-DED SG06 AB SVA 20/1500-DED SG06 CC SVA 20/1500-DED SG06 CE SVA 20/1500-DED SG06 CD SVA 20/1500-DED SG06 FE SVA 20/1500-DED SG06 FD SVA 20/1500-DED SG06 US SVA 20/1500-DED SG06 NO RX-CARVE OUT OTHER 100I NORX-CO OTHR 100%I 232 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit Y1K Y1P Y1V Y1Y Y2P Y2Y Y3A Y3B Y3R Y50 Y5A Y5B Y5R YA5 YAA YAB YAM YAN YB5 YBA YBB YC3 YCE YCP YCS YCT YD4 YE5 YEA YED YEE YEN YEP YF6 YFA YG7 YGA YH8 YJU YJW YJX YJY YLA YLO YOR YRR YSB YSG YSI YSM Plan / Benefit Description DUMMY STANDARD 90%/$10 - POS DUMMY STANDARD 90%/$10-POS COBRA $10/90% MFP - POS $10/90% MFP - POS COBRA 90/80/70 $300 DED 90/80/70 $300 DED 90/80/70 $300 DED CAL CBRA NO RX-CARVE OUT OTHER 50I 90/80/70 $500 DED 90/80/70 $500 DED 90/80/70 $500 DED CAL CBRA $5G/$5B/$20NF $10G/$10B/$20NF $5/$10/$20 SH ALAMEDA PLUS W/OPT DNTL $10G/$10B/$20NF $5G/$5B/$20NF $10G/$10B/$20NF $5/$10/$20 SV 10/500D 05 USERRA YOLO CLASSIC I W/EPO DDS YOLO CLASSIC I W/ODP DDS YOLO CLASSIC I SH CONTRA COSTA PLS-LO DNT SV 10/500D 05 CAL CB SV 10/500D 05 FED CB DIS SVA 15/250A YUM 08 MCC YOLO DELUXE SH07 MCC YOLO EP SH07 MC COMP YOLO SH07 MCC YOLO PP SH07 SV 10/500D 05 FED CB EXT SVA 15/250A YUM 08 CB SV 10/500D 05 CAL CB EXT SVA 15/250A YUM 08 AB SV 10/500D 05 CAL CB DIS ARP MCC YOLO PP SH08 ARP MCC YOLO SH08 ARP MCC YOLO DLX SH08 ARP MCC YOLO EP SH08 KEENAN COMP YOLO GR07 RESERVED RESERVED SH RIVERSIDE PLUS W/OP DNT SH SAN BERN PLUS W/OPT DNT SH SAN DIEGO PLUS W/OP DNT RESERVED SH SACRAMENTO PLS W/OP DNT 233 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit YSN YSO YSX YUA YUB YUC YVN YXA YXJ YXZ YYA YYB YYJ YYX YZ2 YZ3 YZ4 YZ5 YZ6 YZ7 YZ8 YZ9 YZA YZC YZZ Z2P Z2R Z2T Z5R Z8P ZA2 ZA3 ZA4 ZA5 ZA6 ZA7 ZA8 ZA9 ZAA ZAB ZAC ZAD ZAE ZAF ZAG ZAH ZAJ ZAK ZAL ZAM Plan / Benefit Description SH SAN FRAN PLUS W/OPT DNT RESERVED SH SANTA CLARA PLUS-LO DNT $5G/$10B/$25NF $5G/$15B/$25NF $10G/$10B/$25NF RESERVED SVA 15/250A YUM 06 SVA 15/250A YUM 06 AB SVA 15/250A YUM 06 CB SV 10/500D 05 SV 10/500D 05 CB SV 10/500D 05 AB SV 20-40/400D NAT'L 06 AB SVA 40-60/2000-DED SG06 CB SVA 40-60/2000-DED SG06 AB SVA 40-60/2000-DED SG06 CC SVA 40-60/2000-DED SG06 CE SVA 40-60/2000-DED SG06 CD SVA 40-60/2000-DED SG06 FE SVA 40-60/2000-DED SG06 FD SVA 40-60/2000-DED SG06 US SVA 40-60/2000-DED SG06 NON STD $5/80 PLAN NON STD $5/80 PLAN CBRA 10-15/50A T1A NON-AARP GR8 10-20/750A T2A NO-AARP GR8 15-25/200D T3A NO-AARP GR8 15-25/130D T2B NO-AARP GR8 10-20/200A T1C NO-AARP GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 10/100% SCEET 05 SV 10/100% SCEET 05 CB SP 10/100% SCEET 05 SP 10/100% SCEET 05 CB SV 5/100% SCEET 05 SV 5/100% SCEET 05 CB SV 15/100% SCEET 05 SV 15/100% SCEET 05 CB SV 10/100% SCEET 05 AB SP 10/100% SCEET 05 SP 10/100% SCEET 05 CB SH ALAMEDA PLUS W/HI DNTL 234 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ZAN ZAP ZAQ ZAR ZB2 ZB3 ZB4 ZB5 ZB6 ZB7 ZB8 ZB9 ZC2 ZC3 ZC4 ZC5 ZC6 ZC7 ZC8 ZC9 ZCJ ZCT ZD2 ZD3 ZD4 ZD5 ZD6 ZD7 ZD8 ZD9 ZDE ZDN ZDP ZE2 ZE3 ZE4 ZE5 ZE6 ZE7 ZE8 ZE9 ZEJ ZF2 ZF3 ZF4 ZF5 ZF6 ZF7 ZF8 ZF9 Plan / Benefit Description SP 10/100% SCEET 05 SP 10/100% SCEET 05 CB SP 15/100% SCEET 05 SP 15/100% SCEET 05 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SP 10/100% SCEET 05 AB SH CONTRA COSTA PLS-HI DDS RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO MCC SANTA CRUZ EP SH07 MC COMP SANTA CRUZ SH07 MCC SANTA CRUZ PP SH07 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 5/100% SCEET 05 AB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 235 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ZG2 ZG3 ZG4 ZG5 ZG6 ZG7 ZG8 ZG9 ZGJ ZH2 ZH3 ZH4 ZH5 ZH6 ZH7 ZH8 ZH9 ZJ2 ZJ3 ZJ4 ZJ5 ZJ6 ZJ7 ZJ8 ZJ9 ZK2 ZK3 ZK4 ZK5 ZK6 ZK7 ZK8 ZK9 ZKJ ZLO ZLS ZM2 ZM3 ZM4 ZM5 ZM6 ZM7 ZM8 ZM9 ZN2 ZN3 ZN4 ZN5 ZN6 ZN7 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 15/100% SCEET 05 AB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SP 10/100% SCEET 05 AB RESERVED SH LA PLUS W/HI OPT DENTAL RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 236 of 640 Plan Benefit - CA State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Plan / Benefit ZN8 ZN9 ZNJ ZOR ZP2 ZP3 ZP4 ZP5 ZP6 ZP7 ZP8 ZP9 ZPR ZQJ ZR2 ZR3 ZR4 ZR5 ZR6 ZR7 ZR8 ZR9 ZRR ZSB ZSG ZSI ZSN ZSO ZSX ZUC ZUE ZUP ZVN ZZ2 ZZ3 ZZ4 ZZ5 ZZ6 ZZ7 ZZ8 ZZ9 ZZA ZZZ Plan / Benefit Description RESERVED PPO RESERVED PPO SP 10/100% SCEET 05 AB SH ORANGE PLUS W/HI OP DNT RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A GR08 SP 15/100% SCEET 05 AB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SH RIVERSIDE PLS W/HI DNTL SH SAN BERN PLUS W/HI DNTL SH SAN DIEGO PLS W/HI DNTL RESERVED SH SAN FRAN PLUS W/HI DNTL RESERVED SH SANTA CLARA PLUS-HI DNT SANTA CRUZ CLASSIC I S CRUZ CLSC I W/EPO DDS S CRUZ CLSC I W/ODP DDS RESERVED SV 35/600D SG06 CB SV 35/600D SG06 AB SV 35/600D SG06 CC SV 35/600D SG06 CE SV 35/600D SG06 CD SV 35/600D SG06 FE SV 35/600D SG06 FD SV 35/600D SG06 US SV 35/600D SG06 HISTORICAL PLAN 237 of 640 Plan Benefit - CO Cap/Eligibility CP7810 Assigned Plan Benefit Codes & Descriptions State CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO Plan / Benefit 0AA 1AA 1AB 1AC 2AB 2AC 2AD 2AE 2AF 2AG 2AH 2AJ 2AK 2AN 2AY 2BF 2BG 2BH 2BL 2CF 2CG 2CH 2DF 2DG 2DH 2FH 2FL 2GH 2HH 2JH 2KH 2MH 2NH 2PH 2PT 2QH 2UH 2VH 2WH 2XH 2YH 2ZA Plan / Benefit Description SV 30/250D 05 15 SH-RX05 7.50 SH-RX05 10 SH-RX05 7.5/15 SH-RX05 7/14 GR-RX05 10/20 GR-RX05 10/25L GR-RX05 7/14 I GR-RX05 10/20 I GR-RX05 10/25L I GR-RX05 15/15L SH-RX05 12/12 SH-RX05 4/20/40 LO GR-RX07 4/25/50 HI GR-RX07 7/14 IM GR RX05 10/20 IM GR-RX05 10/25L IM GR-RX5 10/25/50 RX-GR08 7/14 I+ GR-RX05 10/20 I+ GR-RX05 10/25L I+ GR-RX05 7/14 II GR-RX05 10/20 II GR-RX05 10/25L II GR-RX5 4/15/30 RX-GR08 5/20/45 RX-GR08 4/20/40 RX-GR08 4/15/30 RX-GR08 4/20/40 RX-GR08 4/25/50 RX-GR08 4/25/45 RX-GR08 4/28/55 RX-GR08 4/28/58 RX-GR08 15/45/60 GR-RX07 4/25/50 RX-GR08 10/25/50 RX-GR08 10/25/50 RX-GR08 5/20/45 RX-GR08 5/20/45 RX-GR08 4/10/20 RX-GR08 0/0 GR-RX07 238 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO 2ZB 2ZC 2ZD 2ZE 2ZF 3AC 3AD 3AE 3AG 3AH 3AJ 3BG 3BH 3BJ 3CG 3CH 3CJ 3DG 3DH 3DJ 3HP 3ZE 3ZF 3ZG 3ZH 3ZJ 3ZK 3ZL 3ZM 42A 6AH 6AL 6BD 6BH 6BI 6BL 6DH 6DL 6EH 6EL 6FH 6FL 6GP 6GR 6HH 6HL 6HP 6JH 6JL 6KH 6KL 2/40 GR-RX07 5/25 GR-RX07 5/65 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 10/20/40 GR-RX05 15/25/40L GR-RX05 15/25/40 GR-RX05 10/20/40 I GR-RX05 15/25/40L I GR-X05 15/25/40 I GR-RX05 10/20/40 IM GR-RX5 15/25/40L IM GRRX5 15/25/40 IM GRRX5 10/20/40 I+ GR-RX5 15/25/40L I+ GRRX5 15/25/40 I+ GR-RX5 10/20/40 II GR-RX5 15/25/40L II GR-X5 15/25/40 II GR-RX5 5/30/45 GR-RX07 5/10/20 GR-RX07 10/20/35 GR-RX07 10/20/35 GR-RX07 10/25/55 GR-RX07 10/40/75 GR-RX07 7/20/50% GR-RX07 2/30/60 GR-RX07 10/25/50 GR-RX07 MCC 3 DEN/SPRINGS GR08 0/0 HI GR-RX07 0/0 LO GR-RX07 7/14 GR-RX06 2/30/60 HI GR-RX07 7/14 I GR-RX06 2/30/60 LO GR-RX07 2/40 HI GR-RX07 2/40 LO GR-RX07 5/25 HI GR-RX07 5/25 LO GR-RX07 5/65 HI GR-RX07 5/65 LO GR-RX07 8.50/26.45/50% SH6 10/20 GR-RX06 5/10 HI GR-RX07 5/10 LO GR-RX07 8.50/26.45/50% SH6 5/10/20 HI GR-RX07 5/10/20 LO GR-RX07 7/14 HI GR-RX07 7/14 LO GR-RX07 239 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO 6LH 6LL 6MA 6MH 6ML 6NH 6NL 6NM 6PH 6PL 6PP 6QH 6QI 6QL 6QR 6RH 6RL 6RP 6SH 6SL 6TH 6TL 6TP 6UH 6UL 6VM 6WH 6YI 6YR 7AA 7AB 7AC 7AD 7AQ 7AR 7BD 7BH 7BI 7BL 7BR 7CD 7CI 7CM 7DD 7DH 7DL 7DM 7DR 7ED 7EH 7EL 7/20/50% HI GR-RX7 7/20/50% LO GR-RX7 10/25%/40% RX-GR06 10/20 HI GR-RX07 10/20 LO GR-RX07 10/20/40 HI GR-RX7 10/20/40 LO GR-RX7 5/15/30 GR-RX06 10/20 HI GR-RX07 10/20 LO GR-RX07 8.50/26.85/50% SH6 10/20/35 HI GR-RX7 10/20/40 I GR-RX06 10/20/35 LO GR-RX7 10/20/40 GR-RX06 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 8.50/27.05/50% SH6 10/25/55 HI GR-RX7 10/25/55 LO GR-RX7 10/40/75 HI GR-RX7 10/40/75 LO GR-RX7 4.50/14.50/50% SH6 15/25/40 HI GR-RX7 15/25/40 LO GR-RX7 5/5 GR-RX06 10/25/50 HI GR-RX7 15/25/40 I GR-RX06 15/25/40 GR-RX06 SV 15/30/300A 05 SV 15/100A IP05 SV 15/30/300A C/C DEN 05 SP 15/200A 05 7/20 GR-RX07 0/0 GR-RX07 7/14 GR-RX07 4/10/20 T1A H GRX7 7/14 I GR-RX07 4/10/20 T1A L GRX7 0/0 FLAT GR-RX07 7/14 GR-RX07 7/14 I GR-RX07 15/25/40 GR-RX07 7/20/30 GR-RX07 4/15/30 T1B H GRX7 4/15/30 T1B L GRX7 15/25/40 GR-RX07 10/10 FLAT GR-RX07 7/7 GR-RX07 4/20/40 T1C H GRX7 4/20/40 T1C L GRX7 240 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO 7EM 7ER 7FD 7FH 7FL 7FM 7FR 7GD 7GM 7GR 7HH 7HI 7HL 7HR 7JH 7JL 7JM 7JR 7KH 7KI 7KL 7KM 7KR 7LH 7LL 7LM 7LR 7MA 7MH 7MI 7ML 7MR 7NH 7NL 7NM 7PH 7PI 7PL 7PM 7PR 7QH 7QI 7QL 7QM 7QR 7RA 7RB 7RC 7RD 7RH 7RL 3/3 FLAT GR-RX07 10/20 GR-RX07 7/7 C GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 3/3/3 GR-RX07 10/20 GR-RX07 10/20/30 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 4/15/30 T2A H GRX7 10/20 I GR-RX07 4/15/30 T2A L GRX7 10/20 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/10 GR-RX07 10/10 GR-RX07 4/28/55 T3B H GRX7 10/20/35 I GR-RX07 4/28/55 T3B L GRX7 5/10/20 GR-RX07 10/20/35 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 5/15 GR-RX07 15/25/40 GR-RX07 10/25%/40% GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 10/20/40 GR-RX07 4/25/50 T2C H GRX7 4/25/50 T2C L GRX7 5/15/30 GR-RX07 4/25/50 T2C H GRX7 10/20/40 I GR-RX07 4/25/50 T2C L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 4/15/30 T2A H GRX7 4/15/30 T2A L GRX7 241 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO 7RM 7SB 7SI 7SR 7TH 7TL 7TM 7TR 7UH 7UL 7UM 7UR 7VH 7VL 7VM 7WH 7WI 7WL 7WM 7WR 7XA 7XB 7XC 7XD 7XE 7XF 7XG 7XH 7XJ 7XL 7XM 7XP 7XQ 7YH 7YI 7YL 7YM 7YR 7ZH 7ZL 7ZM 7ZR 82A 82B 82C 82D 82E 82F 82G 82H 82J 5/15/30 GR-RX07 10/25%/40% GR-RX07 10/20/40 I GR-RX07 10/20/40 GR-RX07 4/28/55 T3B H GRX7 4/28/55 T3B L GRX7 5/5 GR-RX07 10/25/40 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/5 GR-RX07 15/25/40 GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 5/5 GR-RX07 4/20/40 T1C H GRX7 15/25/40 I GR-RX07 4/20/40 T1C L GRX7 5/7.50 GR-RX07 15/25/40 GR-RX07 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/25/50 RDS GR-RX7 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/15/30 T1B H GRX7 4/25/50 RDS GR-RX7 4/15/30 T1B L GRX7 7/14 GR-RX07 5/29/60 N/G SH-RX7 5/29/60 N/G SH-RX7 4/10/20 T1A H GRX7 15/25/40 I GR-RX07 4/10/20 T1A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 242 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO 82K 82L 82M 82N 82P 82Q 82R 82S 82T 82U 82V 82W 82X 82Y 82Z 83A 83B 83C 83D 83E 83F 83G 83H 83J 83K 83L 83M 8AA 8AH 8AR 8B8 8BH 8CH 8DD 8DH 8DR 8ED 8EH 8EM 8ER 8FD 8FH 8GH 8GM 8HD 8HH 8KM 8LH 8LM 8MA 8N8 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 SV 20/35/150D SG 05 0/0 HI C GR-RX07 0/0 C GR-RX07 5/29/60NG RX-SH08 DO NOT USE 2/30/60 HI C GRX07 7/20/30 C GR-RX07 2/40 HI C GR-RX07 10/10 FLAT C GRX07 7/7 C GR-RX07 5/25 HI C GR-RX07 3/3 FLAT C GR-RX07 10/20 C GR-RX07 7/7 C GR-RX07 5/65 HI C GR-RX07 5/10 HI C GR-RX07 5/10 C GR-RX07 10/20/30 C GR-RX07 DO NOT USE 5/10/20 C GR-RX07 7/20/50% HI C GRX7 5/15 C GR-RX07 10/25%/40% C GRX07 5/29/60G RX-SH08 243 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO 8NM 8PH 8PM 8RH 8RM 8SH 8TH 8TM 8TR 8UM 8UR 8VM 8WH 91H 92H 93H 94H 95H 9AN 9AQ 9AR 9AY 9BE 9BH 9BL 9CM 9DH 9DL 9DR 9EH 9EL 9ER 9FD 9FH 9FL 9GE 9GM 9HD 9HH 9HK 9HL 9HN 9HP 9JH 9JL 9KH 9KL 9KS 9LH 9LL 9LM 5/15/30 C GR-RX07 10/20 HI C GR-RX07 5/15/30 C GR-RX07 10/20/35 HI C GRX7 5/15/30 C GR-RX07 10/25/55 HI C GRX7 10/40/75 HI C GRX7 5/5 C GR-RX07 10/25/40 C GR-RX07 5/5 C GR-RX07 15/25/40 C GR-RX07 5/7.50 C GR-RX07 10/25/50 HI C GRX7 15/25/40 HI RX-GR8 10/25/50 HI RX-GR8 10/20/40 HI RX-GR8 10/20 HI RX-GR08 10/40/75 HI C XGR8 4/20/40 LO RX-GR08 7/20 RX-GR08 0/0 RX-GR08 4/25/50 HI RX-GR08 7/14 RX-GR08 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 15/25/40 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 10/10 FLAT C XGR08 4/20/40 T1C H XGR8 4/20/40 T1C L XGR8 10/20 RX-GR08 7/7 C RX-GR08 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 10/20/30 RX-GR08 5/10 RX-GR08 10/20/30 C RX-GR08 4/15/30 T2A H XGR8 4/10/20 RX-GR08 4/15/30 T2A L XGR8 4/15/30 RX-GR08 5/30/45 RX-GR08 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 10/20/35 RX-GR08 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 5/15 C RX-GR08 244 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO 9LP 9LV 9MA 9MH 9MI 9ML 9MR 9NH 9NL 9NM 9PH 9PL 9PT 9PX 9QH 9QL 9RH 9RL 9RP 9RX 9TH 9TL 9UH 9UL 9VH 9VM 9WH 9WI 9WL 9WM 9XH 9XL 9YH 9YL 9ZH 9ZL APF APN AT7 ATP ATQ ATU ATV B6P BAK BAM BVE BVL C27 C7A C7E 5/15 RX-GR08 10/20/35 RX-GR08 10/25%/40% RX-GR08 4/20/40 T2B H XGR8 10/20/40 I RX-GR08 4/20/40 T2B L XGR8 10/20/40 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/15/30 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 15/45/60 RX-GR08 5/29/60 P RX-GR08 4/20/40 T2B H XGR8 4/20/40 T2B L XGR8 4/15/30 T2A H XGR8 4/15/30 T2A L XGR8 5/15/30 RX-GR08 NO RX 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/25/50 T1D H XGR8 5/5 RX-GR08 4/20/40 T1C H XGR8 15/25/40 I RX-GR08 4/20/40 T1C L XGR8 5/7.50 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 10/12V 1YR ACU SH07 10/12V 1YR ACU SH08 ATW-STD SH-WL07 ATW-PLUS SH-WL07 ATW ENHANCED SH08 ATW-PLUS WL-SH07 ATW-STD WL-SH08 15/100% BP AMOCO GR06 20 BP AMOCO NON-AARP GR08 20/100% BP AMOCO GR07 15/100A BOEING VEBA GR07 15 BO-VEBA NON-AARP GR08 SC 90 ELIGIBILITY ONLY 5/12V 1YR GR-CH07 10/12V 1YR GR-CH07 245 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO C7F C7G C7H C7J C7K C7L C7M C7P C7S C7U C7W C7Y C9A CAB CAC CAD CAE CAF CGL CGS CGV CGX CHU CHW CPA CRR D6V D8B D8E D8J DA7 DA8 DAD DAI DAV DAW DAY DB7 DB8 DBA DBI DBV DBW DBY DF6 DF7 DF8 DFI DFV DFW DFY 10/20V 1YR GR-CH07 10/30V 1YR GR-CH07 15/12V 1YR GR-CH07 15/20V 1YR GR-CH07 0/20V 1YR GR-CH07 15/30V 1YR GR-CH07 20/12V 1YR GR-CH07 5/10V 1YR GR-CH07 30/12V 1YR GR-CH07 5/20V 1YR GR-CH07 5/30V 1YR GR-CH07 5/40 1YR GR-CH07 CHIRO SC90 5/12V GR-CH05 15/12V GR-CH05 20/12V GR-CH05 10/12V GR-CH05 10/20V GR-CH05 CAREGIVER LITE SH06 CAREGIVER GR05 CAREGIVER CG-GR08 CAREGIVER ENHANCED 10/12V 1YR SH-CH07 10/12V 1YR CH-SH08 RESERVED PFFS 10/12V GR-CH07 DENTAL - VISION GR06 PREVENTIVE DN-SH08 $20 469 DN-SH08 $5 260 DN-SH08 ARP MCC 3 DEN 260 SH08 ARP MCC 3 DEN 260-PL SH08 OPTIONAL SH-DN05 ARP MCC 3 DEN EP-PL SH08 ARP MCC 3 DEN PLUS SH08 ARP MCC 3 DEN SH08 ARP MCC 3 DEN EP SH08 ARP MCC 1 DEN 260 SH08 ARP MCC 1 DEN 260-PL SH08 100%/70% DISCOUNT GR-DN07 ARP MCC 1 DEN EP-PL SH08 ARP MCC 1 DEN PLUS SH08 ARP MCC 1 DEN SH08 ARP MCC 1 DEN EP SH08 $0 466 SH-DN06 ARP MCC ES DEN 260 SH08 ARP MCC ES DEN 260-PL SH08 ARP MCC ES DEN EP-PL SH08 ARP MCC ES DEN PLUS SH08 ARP MCC ES DEN SH08 ARP MCC ES DEN EP SH08 246 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO DG7 DG8 DGI DGV DGW DGY DMA DMG DMQ DN2 DN3 DN6 DN7 DN8 DNA DQ6 DRR FC2 FCE FCN FSL FT2 FTE FTL FTN FZ7 FZW FZY GD7 GDW GK7 GK8 GKI GKV GKW GKY GZ7 GZ8 GZI GZV GZW GZY H6P H8A H8G HAA HAB HAC HAD HAN HBJ ARP MCC 2 DEN 260 SH08 ARP MCC 2 DEN 260-PL SH08 ARP MCC 2 DEN EP-PL SH08 ARP MCC 2 DEN PLUS SH08 ARP MCC 2 DEN SH08 ARP MCC 2 DEN EP SH08 20% SH-DM05 10/100% GR06 10/100% NON-AARP GR08 SO 460 GRP BILLED - GR SO 462 INDIV BILLED - GR $6 260 SH-DN06 $5 260 SH-DN07 SO 460 GRP BILLED DN-GR08 PREVENTIVE SH-DN07 $20 469 SH-DN06 10-20/200A DERP GR07 15/30 FREMONT C SH06 D260 15/30 FREMONT C SH06 EPO 15/30 FREMONT C SH06 SILVER SNEAKER SH/GR-WL07 MCC FREMONT 260 SH07 MCC FREMONT EP SH07 SILVER SNEAKER SH/GR-WL08 MC COMP FREMONT SH07 ARP MCC FREMONT 260 SH08 ARP MCC FREMONT SH08 ARP MCC FREMONT EP SH08 ARP MCC ES C SP 260 SH08 ARP MCC ES C SP SH08 ARP MCC 1 C SP 260 SH08 ARP MCC 1 C SP 260-PL SH08 ARP MCC 1 C SP EP-PL SH08 ARP MCC 1 C SP PLUS SH08 ARP MCC 1 C SP SH08 ARP MCC 1 C SP EP SH08 ARP MCC 3 C SP 260 SH08 ARP MCC 3 C SP 260-PL SH08 ARP MCC 3 C SP EP-PL SH08 ARP MCC 3 C SP PLUS SH08 ARP MCC 3 C SP SH08 ARP MCC 3 C SP EP SH08 15-25/100A GR06 0/500A 3YRS PL HA-SH08 0/800A 3YRS HA-SH08 0/400A 3YR SH-HA05 0/300A 2YR GR-HA05 0/500A 2YR GR-HA05 0/500A 3YR GR-HA05 300A/24M GR-HA07 HEARING AID $500 EVERY 3YR 247 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO HD6 HDE HF6 HHE HK8 HOA HOE HOI HPE HPG HRJ HRP HRR HTC IAA JAN JCE JCN JCP JDN JEE JEN JEP JME JMN JMP LAD LOK LOL MTK MTM NL8 O1Q O1R O1W O2Q O2R O2W O33 O3G O3Q O3R O3W O4Q O4R O4W O5Q O5R O5W O6Q O6R RESERVED HEARING SH06 300A 2YRS HA-GR08 25/400A 3 YRS SH-HA06 500A 3YRS HA-GR08 500A 3YRS 0PREM HA-GR08 RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED PFFS 20-40/500A HP GR07 0/800A 3YRS SH-HA07 0/500A 3YRS PL SH-HA07 300A GR-HA07 500A 2YRS HA-GR08 INFERTILITY SH05 MC COMP MESA SH07 10/25 MESA C SH06 EPO 10/25 MESA C SH06 10/25 MESA C SH06 ODP MC COMP ESS MESA SH07 5/10 MESA CE SH06 EPO 5/10 MESA CE SH06 5/10 MESA CE SH06 ODP 5/10 MESA M SH06 EPO 5/10 MESA M SH06 5/10 MESA M SH06 ODP 20-30/250A LOKHEED GR06 20-30/250A LOKHEED GR07 20-30 LOKHEED NON-AARP GR8 10/5V 1YR MSG THRPY SH07 10/5V 1YR MSG THRPY SH08 24HR NURSLINE WL-SH/GR08 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 10/100% NAT'L-GR06 15/250A NAT'L-GR06 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 248 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO O6W O7Q O7R O7W O8Q O8R O8W O9Q O9R O9W OC1 OC3 OC5 OD1 OD3 ODE ODF ODG ODK OE1 OE3 OE5 OE8 OF1 OF3 OF5 OG3 OG5 OH1 OH3 OH5 OP3 OP4 OP5 OR1 OR3 OR5 ORX OTZ OVW OY8 OYY P8B PAA PAB PAD PAE PAF PAG PAH PAK 5-20/100A T1B GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 5/100% NAT'L GR 06 5/100% NAT'L GR 06 5/100% NAT'L GR 06 10/100% NAT'L-GR06 10/100% NAT'L GR 06 5/100% AARP GR086 10/100% AARP GR08 15/250A AARP GR08 20/100% NON-AARP GR08 10-20/250A NAT'L GR 06 10-20/250A NAT'L GR 06 10-20/250A NAT'L GR 06 10-20/250A AARP GR08 10-20/500A NAT'L GR 06 10-20/500A NAT'L GR 06 10-20/500A NAT'L GR 06 15/250A NAT'L GR 06 15/250A NAT'L GR 06 15-25/500A NAT'L GR 06 15-25/500A NAT'L GR 06 15-25/500A NAT'L GR 06 20-40/250A NAT'L GR 06 20-40/250A NAT'L GR 06 20-40/250A NAT'L GR 06 20/100% NAT'L GR 06 20/100% NAT'L GR 06 20/100% NAT'L GR 06 OTHR RX-NOT PS GR06 20-40/250A AARP GR08 10/100% NON-AARP GR08 10-20/250A NON-AARP GR08 15/250A NON-AARP GR08 20-30 PERA NON-AARP GR08 PPO - PFFS PPO - PFFS PPO - PFFS PPO - PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS 249 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO PET PEW PIE PIF PIG PIH PII PIK PIL PIN PIO PLP PN7 PNW PNY PYI QA2 QAN QB1 QB2 QB7 QB9 QBE QBN QC2 QCE QCN QL1 QL2 QL7 QL9 QLE QLJ QLN QM2 QME QMN RPE RPX S25 S2C S2D S2E S2F S2G S2H S2J S2P S2R S2W S34 20-30/500A PERA GR07 20-30 PERA NON-AARP GR08 RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS PAYMENT LAG PREMIUM ALLOC ARP MCC PUEBLO 260 SH08 ARP MCC PUEBLO SH08 ARP MCC PUEBLO EP SH08 RESERVED PFFS MCC ESS C SPRING 260 SH07 MC COMP ESS C SPRING SH07 MCC 1 C SPRING 260-PL SH07 MCC 1 C SPRING 260 SH07 MCC 1 C SPRING EP-PL SH07 MCC 1 C SPRING PLUS SH07 MCC 1 C SPRING EP SH07 MC COMP 1 C SPRING SH07 10/30 COLSPR C SH06 D260 10/30 COLSPR C SH06 EPO 10/30 COLSPR C SH06 MCC 3 C SPRING 260-PL SH07 MCC 3 C SPRING 260 SH07 MCC 3 C SPRING EP-PL SH07 MCC 3 C SPRING PLUS SH07 MCC 3 C SPRING EP SH07 QUEST DIAGNOSTICS MC COMP 3 C SPRING SH07 0 COLSPR M SH06 D260 0 COLSPR M SH06 EPO 0 COLSPR M SH06 RESPITE/PERS CARE SH07 RESPITE/PERS CARE WL-SH08 10-20/250A NON-AARP GR08 5/100% NAT'L-GR05 10/100% NAT'L-GR05 10-20/250A NAT'L-GR05 10-20/500A NAT'L-GR05 15/250A NAT'L-GR05 15-25/500A NAT'L-GR05 15-20/100A TOWERS PER-GR05 20-40/250A NAT'L-GR05 20/100% NAT'L-GR05 10/100% REGIONAL-GR05 10-20/250A AARP GR08 250 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO S3C S3D S3E S3F S3G S3H S3P S3R S3W S4H SBA SC2 SCA SD2 SD3 SDA SDB SF2 SFC SL2 SLA SMA SP2 SPA SSP SSR SV2 SVA TA6 TAX TP1 TPH TPL UB2 UBE UBN UC2 UCE UCN V27 V2F V8P V8Q V8R V8S V8T V8U V8V V8W V8X VAA 5/100% NAT'L-GR06 10/100% NAT'L-GR06 10-20/250A NAT'L-GR06 10-20/500A NAT'L-GR06 15/250A NAT'L-GR06 15-25/500A NAT'L-GR06 20-40/250A NAT'L-GR06 20/100% NAT'L-GR06 15-25/500A AARP GR08 20-40/250A NON-AARP GR08 20-30 PART B-SH05 15/500A CO SPRG I WD-SH05 15/500A CO SPRG I-SH05 15-30/500A I W/D-SH05 10-25/400A II W/D-05 15-30/500A PLAN I-SH05 10-25/400A PLAN II-SHO5 FREMONT CO W/D-SH05 FREMONT COUNTY I-SH05 15/300A LARIMER I WD-SH05 15/300A LARIMER I-SH05 15-25/200A MESA-SH05 15-40/750A PUEBLO W/D-SH05 15-40/750A PUEBLO-SH05 SILVER SNEAKERS SH05 SLV SNEAK/FITNESS BEN GR06 15-30/700 VALUE W/D-SH05 15-30/700 VALUE PLAN-SHO5 RESERVED TRANS SH06 PCCO PREMIUM TAX THERAPHYSICS 5-10/100% GR06 15-20/100A GR06 MCC PUEBLO 260 SH07 MCC PUEBLO EP SH07 MC COMP PUEBLO SH07 15/30 PUEBLO C SH06 D260 15/30 PUEBLO C SH06 EPO 15/30 PUEBLO C SH06 SC 20 ELIGIBILITY ONLY 0/70A TOWERS GR-VN05 VSP 0 REFRAC 1/V YR VN-GR08 5 REFRAC 1/V YR VN-GR08 10 REFRAC 1/V YR VN-GR08 15 REFRAC 1/V YR VN-GR08 20 REFRAC 1/V YR VN-GR08 25 REFRAC 1/V YR VN-GR08 30 REFRAC 1/V YR VN-GR08 35 REFRAC 1/V YR VN-GR08 40 REFRAC 1/V YR VN-GR08 0/150A SH-VN05 VSP 251 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO VAC VAD VAE VAF VAG VAH VAJ VAK VAM VB6 VC2 VCE VCN VDA VE2 VEE VEN VFP VFQ VG6 VGP VGQ VJQ VKP VM2 VME VMN VMQ VN2 VNQ VP6 VPE VPP VQ1 VQ2 VQ7 VQ9 VQD VQE VQF VQN VQP VRR VSF VSQ VU1 VU2 VU7 VU9 VUE VUN 0/125A GR-VN05 VSP 0/75A GR-VN05 VSP 25/150A SH-VN05 0/150A GR-VN05 25 EXAM ONLY SH-VN05 VSP 30 EXAM ONLY SH-VN05 40 EXAM ONLY SH-VN05 15/150A SH-VN05 VSP 10 EXAM ONLY SH-VN05 25/150A 2 YRS SH-VN06 10/30 DV CLSC SH06 D260 10/30 DENVER C SH06 EPO 10/30 DENVER C SH06 15/70A GR-VN07 5/10 DENVER CE SH06 D260 5/10 DENVER CE SH06 EPO 5/10 DENVER CE SH06 0/75A 2YRS VN-GR08 0/125A 2YRS VN-GR08 25/75A VN-GR06 5/75A 2YRS VN-GR08 5/125A 2YRS VN-GR08 10/75A 2YRS VN-GR08 10/125A 2YRS VN-GR08 10/20 DENVER M SH06 D260 10/20 DENVER M SH06 EPO 10/20 DENVER M SH06 15/125A 2YRS VN-GR08 10/75A 2YRS GR-VN07 20/75A 2YRS VN-GR08 ADVANCE WELLNESS SH-WL06 RESERVED PFFS 20/125A 2YRS VN-GR08 MCC 1 DENVER 260-PL SH07 MCC 1 DENVER 260 SH07 MCC 1 DENVER EP-PL SH07 MCC 1 DENVER PLUS SH07 30/70A 2YRS VN-SH08 MCC 1 DENVER EP SH07 0/130A 2YRS VN-SH08 MC COMP 1 DENVER SH07 25/70A 2YRS VN-GR08 10/75A GR-VN07 0/130A 2YRS SH-VN07 30/70A 2YRS SH-VN07 MCC ESS DENVER 260-PL SH07 MCC ESS DENVER 260 SH07 MCC ESS DENVER PP-PL SH07 MCC ESS DENVER PLUS SH07 MCC ESS DENVER EP SH07 MC COMP ESS DENVER SH07 252 of 640 Plan Benefit - CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO VV2 VVE VVN VVP VVQ VW1 VW2 VW7 VW9 VWE VWN VWP VWQ VY1 VY2 VY7 VY9 VYE VYN WB6 WPR WPS WPT WQR WQS WQT WRR WRS WRT XAA YC2 YCE YCN YK2 YKE YKN Z2P Z2T Z5R Z8P 15/30 DENVER V SH06 D260 15/30 DENVER V SH06 EPO 15/30 DENVER V SH06 15/75A 2YRS VN-GR08 25/75A 2YRS VN-GR08 MCC 2 DENVER 260-PL SH07 MCC 2 DENVER 260 SH07 MCC 2 DENVER EP-PL SH07 MCC 2 DENVER PLUS SH07 MCC 2 DENVER EP SH07 MC COMP 2 DENVER SH07 25/125A 2YRS VN-GR08 25/70 2YRS VN-GR08 MCC 3 DENVER 260-PL SH07 MCC 3 DENVER 260 SH07 MCC 3 DENVER EP-PL SH07 MCC 3 DENVER PLUS SH07 MCC 3 DENVER EP SH07 MC COMP 3 DENVER SH07 RESERVED HLTH ED SH06 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 NO RX GR05 15/30 LARIMER C SH06 D260 15/30 LARIMER C SH06 EPO 15/30 LARIMER C SH06 MCC LARIMER 260 SH07 MCC LARIMER EP SH07 MC COMP LARIMER SH07 10-15/50A T1A NON-AARP GR8 15-25/200D T3A NO-AARP GR8 15-25/130D T2B NO-AARP GR8 10-20/200A T1C NO-AARP GR8 253 of 640 Plan Benefit - NV Cap/Eligibility CP7810 Assigned Plan Benefit Codes & Descriptions State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit 22B 22C 22H 2AC 2AD 2AE 2AF 2AG 2AH 2AN 2AY 2BL 2FH 2FL 2GH 2HH 2JH 2KH 2MH 2NH 2PH 2QH 2UH 2VH 2WH 2XH 2YH 2ZA 2ZB 2ZC 2ZD 2ZE 2ZF 32A 32B 32C 33B 3AC 3AD 3AE 3AF 3AG Plan / Benefit Description 3/3 BOEING GR-RX05 5/5 EDISON GR-RX05 5/5 BOEING GR-RX05 7/14 GR-RX05 10/20 GR-RX05 10/25L GR-RX05 7/14 I GR-RX05 10/20 I GR-RX05 10/25L I GR-RX05 4/20/40 LO GR-RX07 4/25/50 HI GR-RX07 10/25/50 RX-GR08 4/15/30 RX-GR08 5/20/45 RX-GR08 4/20/40 RX-GR08 4/15/30 RX-GR08 4/20/40 RX-GR08 4/25/50 RX-GR08 4/25/45 RX-GR08 4/28/55 RX-GR08 4/28/58 RX-GR08 4/25/50 RX-GR08 10/25/50 RX-GR08 10/25/50 RX-GR08 5/20/45 RX-GR08 5/20/45 RX-GR08 4/10/20 RX-GR08 0/0 GR-RX07 2/40 GR-RX07 5/25 GR-RX07 5/65 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 10/20/35L GR-RX05 5/15/30 BO GR-RX05 5/15 B-148 GR-RX05 5/15/30 BO RX-GR08 10/20/40 GR-RX05 15/25/40L GR-RX05 15/25/40 GR-RX05 10/20/40 SH-RX05 10/20/40 I GR-RX05 254 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit 3AH 3AJ 3AL 3AM 3LL 3ZE 3ZF 3ZG 3ZH 3ZJ 3ZK 3ZL 3ZM 44E 44F 47D 47H 6AH 6AL 6AR 6BH 6BL 6CM 6DH 6DL 6EH 6EL 6ER 6FH 6FL 6GM 6HH 6HL 6JH 6JL 6JP 6KH 6KI 6KL 6KP 6KR 6LH 6LL 6LR 6MA 6MH 6ML 6MR 6NH 6NL Plan / Benefit Description 15/25/40L I GR-X05 15/25/40 I GR-RX05 10/20/40PA SH-RX05 10/25/50P L SH-X05 10/20/50 GR-RX07 5/10/20 GR-RX07 10/20/35 GR-RX07 10/20/35 GR-RX07 10/25/55 GR-RX07 10/40/75 GR-RX07 7/20/50% GR-RX07 2/30/60 GR-RX07 10/25/50 GR-RX07 MCC CLARK GR08 MCC CLARK DLX GR08 MCC NYE GR08 MCC NYE DLX GR08 0/0 HI GR-RX07 0/0 LO GR-RX07 0/0 GR-RX06 2/30/60 HI GR-RX07 2/30/60 LO GR-RX07 15/25/40 GR-RX06 2/40 HI GR-RX07 2/40 LO GR-RX07 5/25 HI GR-RX07 5/25 LO GR-RX07 10/20 GR-RX06 5/65 HI GR-RX07 5/65 LO GR-RX07 5/10 GR-RX06 5/10 HI GR-RX07 5/10 LO GR-RX07 5/10/20 HI GR-RX07 5/10/20 LO GR-RX07 8.50/26.70/50% SH6 7/14 HI GR-RX07 10/20/35 I GR-RX06 7/14 LO GR-RX07 8.50/26.70/50% SH6 10/20/35 GR-RX06 7/20/50% HI GR-RX7 7/20/50% LO GR-RX7 10/20/35 GR-RX06 10/25%/40% RX-GR06 10/20 HI GR-RX07 10/20 LO GR-RX07 10/20/40 GR-RX06 10/20/40 HI GR-RX7 10/20/40 LO GR-RX7 255 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit 6PH 6PL 6PM 6QH 6QL 6RH 6RL 6SH 6SL 6TH 6TL 6UC 6UH 6UL 6UM 6VM 6WH 6YM 7AQ 7AR 7BD 7BH 7BI 7BL 7BR 7CD 7CI 7CM 7DD 7DH 7DL 7DM 7DR 7ED 7EH 7EL 7EM 7ER 7FD 7FH 7FL 7FM 7FR 7GD 7GM 7GR 7HH 7HI 7HL 7HR Plan / Benefit Description 10/20 HI GR-RX07 10/20 LO GR-RX07 5/15/30 GR-RX06 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 10/25/55 HI GR-RX7 10/25/55 LO GR-RX7 10/40/75 HI GR-RX7 10/40/75 LO GR-RX7 10/20/35 GR-RX06 15/25/40 HI GR-RX7 15/25/40 LO GR-RX7 5/5 GR-RX06 5/5 GR-RX06 10/25/50 HI GR-RX7 7/14 GR-RX06 7/20 GR-RX07 0/0 GR-RX07 7/14 GR-RX07 4/10/20 T1A H GRX7 7/14 I GR-RX07 4/10/20 T1A L GRX7 0/0 FLAT GR-RX07 7/14 GR-RX07 7/14 I GR-RX07 15/25/40 GR-RX07 7/20/30 GR-RX07 4/15/30 T1B H GRX7 4/15/30 T1B L GRX7 15/25/40 GR-RX07 10/10 FLAT GR-RX07 7/7 GR-RX07 4/20/40 T1C H GRX7 4/20/40 T1C L GRX7 3/3 FLAT GR-RX07 10/20 GR-RX07 7/7 C GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 3/3/3 GR-RX07 10/20 GR-RX07 10/20/30 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 4/15/30 T2A H GRX7 10/20 I GR-RX07 4/15/30 T2A L GRX7 10/20 GR-RX07 256 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit 7JH 7JL 7JM 7JR 7KH 7KI 7KL 7KM 7KR 7LH 7LL 7LM 7LR 7MA 7MH 7MI 7ML 7MR 7NH 7NL 7NM 7PH 7PI 7PL 7PM 7PR 7QH 7QI 7QL 7QM 7QR 7RA 7RB 7RC 7RD 7RH 7RL 7RM 7SB 7SI 7SR 7TH 7TL 7TM 7TR 7UC 7UH 7UL 7UM 7UR Plan / Benefit Description 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/10 GR-RX07 10/10 GR-RX07 4/28/55 T3B H GRX7 10/20/35 I GR-RX07 4/28/55 T3B L GRX7 5/10/20 GR-RX07 10/20/35 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 5/15 GR-RX07 15/25/40 GR-RX07 10/25%/40% GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 10/20/40 GR-RX07 4/25/50 T2C H GRX7 4/25/50 T2C L GRX7 5/15/30 GR-RX07 4/25/50 T2C H GRX7 10/20/40 I GR-RX07 4/25/50 T2C L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 4/15/30 T2A H GRX7 4/15/30 T2A L GRX7 5/15/30 GR-RX07 10/25%/40% GR-RX07 10/20/40 I GR-RX07 10/20/40 GR-RX07 4/28/55 T3B H GRX7 4/28/55 T3B L GRX7 5/5 GR-RX07 10/25/40 GR-RX07 10/20/35 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/5 GR-RX07 15/25/40 GR-RX07 257 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit 7VH 7VL 7VM 7WH 7WI 7WL 7WM 7WR 7XA 7XB 7XC 7XD 7XE 7XF 7XG 7XH 7XJ 7XL 7XM 7XP 7YH 7YI 7YL 7YM 7YR 7ZH 7ZL 7ZM 7ZR 82A 82B 82C 82D 82E 82F 82G 82H 82J 82K 82L 82M 82N 82P 82Q 82R 82S 82T 82U 82V 82W Plan / Benefit Description 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 5/5 GR-RX07 4/20/40 T1C H GRX7 15/25/40 I GR-RX07 4/20/40 T1C L GRX7 5/7.50 GR-RX07 15/25/40 GR-RX07 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/25/50 RDS GR-RX7 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/15/30 T1B H GRX7 4/25/50 RDS GR-RX7 4/15/30 T1B L GRX7 7/14 GR-RX07 5/29/60 N/G SH-RX7 4/10/20 T1A H GRX7 15/25/40 I GR-RX07 4/10/20 T1A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 258 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit 82X 82Y 82Z 83A 83B 83C 83D 83E 83F 83G 83H 83J 83K 83L 83M 8AH 8AR 8B8 8BH 8CH 8DD 8DH 8DR 8ED 8EH 8EM 8ER 8FD 8FH 8GH 8GM 8HD 8HH 8KM 8LH 8LM 8MA 8NM 8PH 8PM 8RH 8RM 8SH 8TH 8TM 8TR 8UM 8UR 8VM 8WH Plan / Benefit Description 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 0/0 HI C GR-RX07 0/0 C GR-RX07 5/29/60NG RX-SH08 DO NOT USE 2/30/60 HI C GRX07 7/20/30 C GR-RX07 2/40 HI C GR-RX07 10/10 FLAT C GRX07 7/7 C GR-RX07 5/25 HI C GR-RX07 3/3 FLAT C GR-RX07 10/20 C GR-RX07 7/7 C GR-RX07 5/65 HI C GR-RX07 5/10 HI C GR-RX07 5/10 C GR-RX07 10/20/30 C GR-RX07 DO NOT USE 5/10/20 C GR-RX07 7/20/50% HI C GRX7 5/15 C GR-RX07 10/25%/40% C GRX07 5/15/30 C GR-RX07 10/20 HI C GR-RX07 5/15/30 C GR-RX07 10/20/35 HI C GRX7 5/15/30 C GR-RX07 10/25/55 HI C GRX7 10/40/75 HI C GRX7 5/5 C GR-RX07 10/25/40 C GR-RX07 5/5 C GR-RX07 15/25/40 C GR-RX07 5/7.50 C GR-RX07 10/25/50 HI C GRX7 259 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit 91H 92H 93H 94H 95H 9AN 9AQ 9AR 9AY 9BE 9BH 9BL 9CM 9DH 9DL 9DR 9EH 9EL 9ER 9FD 9FH 9FL 9GE 9GM 9HD 9HH 9HK 9HL 9HN 9JH 9JL 9KH 9KL 9KS 9LH 9LL 9LM 9LP 9LR 9LV 9MA 9MH 9MI 9ML 9MR 9NH 9NL 9NM 9PH 9PL Plan / Benefit Description 15/25/40 HI GR-RX8 10/25/50 HI GR-RX8 10/20/40 HI GR-RX8 10/20 HI GR-RX08 10/40/75 HI C XGR8 4/20/40 LO RX-GR08 7/20 RX-GR08 0/0 RX-GR08 4/25/50 HI RX-GR08 7/14 RX-GR08 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 15/25/40 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 10/10 FLAT C XGR08 4/20/40 T1C H XGR8 4/20/40 T1C L XGR8 10/20 RX-GR08 7/7 C RX-GR08 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 10/20/30 RX-GR08 5/10 RX-GR08 10/20/30 C RX-GR08 4/15/30 T2A H XGR8 4/10/20 RX-GR08 4/15/30 T2A L XGR8 4/15/30 RX-GR08 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 10/20/35 RX-GR08 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 5/15 C RX-GR08 5/15 RX-GR08 10/20/50 RX-GR08 10/20/35 RX-GR08 10/25%/40% RX-GR08 4/20/40 T2B H CGR8 10/20/40 I RX-GR08 4/20/40 T2B L XGR8 10/20/40 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/15/30 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 260 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit 9PX 9QH 9QL 9RH 9RL 9RP 9RX 9TH 9TL 9UC 9UH 9UL 9VH 9VL 9VM 9WH 9WI 9WL 9WM 9XH 9XL 9YH 9YL 9ZH 9ZL APF APN AT7 ATP ATQ ATU ATV BDA BDL BOQ BVE BVL C27 C2E C7A C7E C7F C7G C7H C7J C7K C7L C7M C7P C7S Plan / Benefit Description 5/29/60 P RX-GR08 4/20/40 T2B H XGR8 4/20/40 T2B L XGR8 4/15/30 T2A H XGR8 4/15/30 T2A L XGR8 5/15/30 RX-GR08 NO RX 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 10/20/35 RX-GR08 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 5/5 RX-GR08 4/20/40 T1C H XGR8 15/25/40 I RX-GR08 4/20/40 T1C L XGR8 5/7.50 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 10/12V 1YR ACU SH07 10/12V 1YR ACU SH08 ATW-STD SH-WL07 ATW-PLUS SH-WL07 ATW ENHANCED SH08 ATW-PLUS WL-SH08 ATW-STD WL-SH08 0/250A BOEING IAM725 GR 06 0 BO IAM 725 NO-AARP GR08 15 BO 148 NO-AARP GR08 15/100A BOEING VEBA GR07 15 BO-VEBA NON-AARP GR08 SC 90 ELIGIBILITY ONLY 15/30V GR-CH06 5/12V 1YR GR-CH07 10/12V 1YR GR-CH07 10/20V 1YR GR-CH07 10/30V 1YR GR-CH07 15/12V 1YR GR-CH07 15/20V 1YR GR-CH07 0/20V 1YR GR-CH07 15/30V 1YR GR-CH07 20/12V 1YR GR-CH07 5/10V 1YR GR-CH07 30/12V 1YR GR-CH07 261 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit C7U C7W C7Y CAB CAC CAD CAE CAG CAH CBO CFP CFV CGL CGR CGS CGU CGV CGX CHU CHW CPA CRR CZC CZD CZF CZG CZH CZJ D6V D8A D8B D8E D8K DAD DBA DL6 DMA DN2 DN3 DNA DNY DQ6 DRR ECP EZC FBB FFS FFV FSL FTL Plan / Benefit Description 5/20V 1YR GR-CH07 5/30V 1YR GR-CH07 5/40 1YR GR-CH07 5/12V GR-CH05 15/12V GR-CH05 20/12V GR-CH05 10/12V GR-CH05 15/12V SH-CH05 20/12V SH-CH05 0/20V BOEING IAM GR-CH06 10/CFI-VEBA NON-AARP GR08 10/100% CFI VEBA GR07 CAREGIVER LITE SH06 CAREGIVER - RESPITE SH05 CAREGIVER GR05 CAREGIVER-RESPITE CG-SH08 CAREGIVER CG-GR08 CAREGIVER ENHANCED 10/12V 1YR SH-CH07 10/12V 1YR CH-SH08 RESERVED PFFS 10/12V GR-CH07 10/12V BO HRLY GR-CH05 15/12V BO-HRLY-F GR-CH05 5/10V EDISON GR-CH05 5/10V UC GR-CH05 15/20V B-148 GR-CH05 5/4V BOEING GR-CH05 DENTAL - VISION GR06 DELUXE OPTION DN-SH08 PREVENTIVE DN-SH08 $20 469 DN-SH08 $0 466 DN-SH08 OPTIONAL SH-DN05 100%/70% DISCOUNT GR-DN07 $0 466 SH-DN06 20% SH-DM05 SO 460 GRP BILLED - GR SO 462 INDIV BILLED - GR PREVENTIVE SH-DN07 DELUXE OPTION SH-DN07 $20 469 SH-DN06 10-20/200A DERP GR07 10/100% EDISON FLEX GR06 10/100% EDISON-F AARP GR08 FITNESS BENEFIT SH06 FITNESS SH/GR-WL07 FITNESS SH/GR-WL08 SILVER SNEAKER SH/GR-WL07 SILVER SNEAKER SH/GR-WL08 262 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit H6P H8A H8B H8D H8G H8H HAA HAB HAC HAD HAE HAF HAH HAJ HAN HBJ HDE HF6 HHE HL8 HOA HOE HOI HPE HRD HRJ HRP HRR HRX HRY HTC HXD KDO KDQ KDU KDV KDW KDX KEO KEQ KEU KEV KEW KEX KFU KFW KFX LAD LAL LJ8 Plan / Benefit Description 15-25/100A GR06 0/500A 3YRS PL HA-SH08 0/1300A 3YRS DX HA-SH08 0/800A 3YRS DX HA-SH08 0/800A 3YRS HA-SH08 0/1600A 3YRS DX HA-SH08 0/400A 3YR SH-HA05 0/300A 2YR GR-HA05 0/500A 2YR GR-HA05 0/500A 3YR GR-HA05 15/400A GR-HA05 35%D GR-HA05 1 EAR 3YR GR-HA05 1PR 3YR GR-HA05 300A/24M GR-HA07 HEARING AID $500 EVERY 3YR 300A 2YRS HA-GR08 25/400A 3 YRS SH-HA06 500A 3YRS HA-GR08 400A 3YRS 0PREM HA-GR08 RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED PFFS 0/800A 3YRS DX SH-HA07 0/800A 3YRS SH-HA07 0/500A 3YRS PL SH-HA07 300A GR-HA07 0/1600A 3YRS DX SH-HA07 0/1300A 3YRS DX SH-HA07 500A 2YRS HA-GR08 1 EAR 3YR HA-GR08 ARP MCC CLK PL-DLX SH08 ARP MCC CLK PP-PL SH08 ARP MCC CLK PP SH08 ARP MCC CLK PLUS SH08 ARP MCC CLK SH08 ARP MCC CLK DLX SH08 ARP MCC VA CLK PL-DLX SH08 ARP MCC VA CLK PP-PL SH08 ARP MCC VA CLK PP SH08 ARP MCC VA CLK PLUS SH08 ARP MCC VA CLK SH08 ARP MCC VA CLK DLX SH08 ARP MCC ES CLK PP SH08 ARP MCC ES CLK SH08 ARP MCC ES CLK DLX SH08 20-30/250A LOKHEED GR06 15/100% LACERS GR07 15 LACERS NON-AARP GR08 263 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit LOC LOK LOL LRI MTK MTM NAU NAW NAX NBU NBW NBX NCE NCN NCS NEE NEN NES NL8 NME NMN NMS NTB NTL O1Q O1R O1W O2A O2K O2M O2Q O2R O2S O2W O3D O3E O3Q O3R O3W O4Q O4R O4W O5Q O5R O5W O6Q O6R O6W O7Q O7R Plan / Benefit Description DO NOT USE 20-30/250A LOKHEED GR07 20-30 LOKHEED NON-AARP GR8 LIABILITY/RECOVERY INFO 10/5V 1YR MSG THRPY SH07 10/5V 1YR MSG THRPY SH08 ARP MCC NYE PP SH08 ARP MCC NYE SH08 ARP MCC NYE DLX SH08 ARP MCC ES NYE PP SH08 ARP MCC ES NYE SH08 ARP MCC ES NYE DLX SH08 5/10 NYE C SH06 EPO 5/10 NYE C SH06 5/10 NYE C SH06 ODP 0 NYE CE SH06 EPO 0 NYE CE SH06 0 NYE CE SH06 ODP 24HR NURSLINE WL-SH/GR08 0 NYE M SH06 EPO 0 NYE M SH06 0 NYE M SH06 ODP 0/24-1W NON-ER TRANS SH07 0/24-1W NON-ER TRANS SH08 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 0/100% BOEING-GR05 10/100% BOEING HRLY-GR05 15/100% BOEING HRLY-F-GR05 10-20/750A T2A GR07 15-25/200D T3A GR07 15/200A BOEING 148-GR05 10-15/50A T1A GR07 10/100% NAT'L-GR06 10-20/250A NAT'L-GR06 10-20/750A T2A GR07 15-25/200D T3A GR07 10-15/50A T1A GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 5-20/100A T1B GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 264 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit O7W O8E O8K O8Q O8R O8W O9Q O9R O9W OBC OBL OC1 OC2 OC3 OC4 OD2 ODF ODG OE2 OE3 OEB OEC OF1 OF2 OF4 OG1 OG2 OG4 OH1 OH2 OH3 OLV OP1 OP2 OP3 OP4 OR1 OR2 OR3 OR4 ORX OS3 OTZ OU8 OVW OYS OYY PAA PAB PAD Plan / Benefit Description 10-20/200A T1C GR07 10-20/250A NON-AARP GR08 10 BO HRLY NO-AARP GR08 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 10-20/200A T1C GR07 10/100% NON-AARP GR08 10 SDCERA NON-AARP GR08 5/100% NAT'L GR 06 5/100% NAT'L GR 06 5/100% NAT'L GR 06 5/100% NAT'L GR 06 10/100% NAT'L GR 06 10/100% AARP GR08 15/250A AARP GR08 10-20/250A NAT'L GR 06 10-20/250A NAT'L-GR06 15 BO HRLY-F NO-AARP GR08 15 BO SCPEA NO-AARP GR08 10-20/500A NAT'L GR 06 10-20/500A NAT'L GR 06 10-20/500A NAT'L GR 06 15/250A NAT'L GR 06 15/250A NAT'L GR 06 15/250A NAT'L GR 06 15-25/500A NAT'L GR 06 15-25/500A NAT'L GR 06 15-25/500A NAT'L GR 06 5/100% NON-AARP GR08 20-40/250A NAT'L GR 06 20-40/250A NAT'L GR 06 20-40/250A NAT'L GR 06 20-40/250A NAT'L GR 06 20/100% NAT'L GR 06 20/100% NAT'L GR 06 20/100% NAT'L GR 06 20/100% NAT'L GR 06 OTHR RX-NOT PS GR06 10/100% NAT'L-GR06 20-40/250A AARP GR08 10-20/250A NON-AARP GR08 10/100% NON-AARP GR08 15-25/500A AARP GR08 15/250A NON-AARP GR08 RESERVED PFFS RESERVED PFFS RESERVED PFFS 265 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit PAE PAF PAG PAH PAK PCJ PCL PIE PIF PIG PIH PII PIK PIL PIN PIO PLP PYI RCE RCN RCS REE REN RES RLD RLN RLP RME RMN RMS RPE RPL RPX RQ6 RQ9 RQD RQN RQO RQP RY6 RY9 RYD RYN RYO RYP S25 S2A S2C S2D S2E Plan / Benefit Description RESERVED PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS SV $20-$40/$200A PHS 06 SV $20-$40/$200A PHS 06 RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS PAYMENT LAG PREMIUM ALLOC RESERVED PFFS 5/10 CLARK C SH06 EPO 5/10 CLARK C SH06 5/10 CLARK C SH06 ODP 0 CLARK CE SH06 EPO 0 CLARK CE SH06 0 CLARK CE SH06 ODP MCC ESS CLARK DELUXE SH07 MC COMP ESS CLARK SH07 MCC ESS CLARK PP SH07 0 CLARK M SH06 EPO 0 CLARK M SH06 0 CLARK M SH06 ODP RESPITE/PERS CARE SH07 ALREADY USED RESPITE/PERS CARE WL-SH08 MCC CLARK PP-PL SH07 MCC CLARK PLUS SH07 MCC CLARK DELUXE SH07 MC COMP CLARK SH07 MCC CLARK PL-DLX SH07 MCC CLARK PP SH07 MCC VALUE CLARK PP-PL SH07 MCC VALUE CLARK PLUS SH07 MCC VALUE CLARK DELUX SH07 MC COMP VALUE CLARK SH07 MCC VALU CLARK PP-DLX SH07 MCC VALUE CLARK PP SH07 10-20/250A NON-AARP GR08 0/100% BOEING-GR05 5/100% NAT'L-GR05 10/100% NAT'L-GR05 10-20/250A NAT'L-GR05 266 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit S2F S2G S2H S2J S2K S2M S2P S2R S2S S2U S2V S34 S3C S3D S3E S3F S3G S3H S3P S3R SC2 SCA SN2 SNC SSP SSR TA6 TAA TAX TPH TPJ TPL UA7 UCA V27 V2A V2F V2H V2J V2K V2L V4P V8P V8Q V8R V8S V8T V8U V8V V8W Plan / Benefit Description 10-20/500A NAT'L-GR05 15/250A NAT'L-GR05 15-25/500A NAT'L-GR05 15-20/100A TOWERS PER-GR05 10/100% BOEING HRLY-GR05 15/100% BOEING HRLY-F-GR05 20-40/250A NAT'L-GR05 20/100% NAT'L-GR05 15/200A BOEING 148-GR05 15/100% UNIV CAL-GR05 5/100% EDISON INT-GR05 10-20/250A AARP GR08 5/100% NAT'L-GR06 10/100% NAT'L-GR06 10-20/250A NAT'L-GR06 10-20/500A NAT'L-GRO6 15/250A NAT'L-GR06 15-25/500A NAT'L-GR06 20-40/250A NAT'L-GR06 20/100% NAT'L-GR06 5-15/100A CLASSIC W/D-SH05 5-15/100A CLASSIC-SH05 5-20/100A NYE W/D-SH05 5-20/100A NYE-SH05 SILVER SNEAKERS SH05 SLV SNEAK/FITNESS BEN GR06 0/24T NON-ER TRANS SH06 NON-EMERGENCY TRANS SH05 PCNV PREMIUM TAX 5-10/100% GR06 15-20/100A AARP GR08 15-20/100A GR06 10/100A UNITED AL GR-07 20/250A UNIV CA GR06 SC 20 ELIGIBILITY ONLY 0/75A BOHRLY GR-VN05 NEP 0/70A TOWERS GR-VN05 NEP 0 BOEING GR-VN05 NEP 20%D UC GR-VN05 NEP 0/60A B-148 GR-VN05 NEP 0/75A BOHRLY-F GR-VN05 NEP FITNESS BENEFIT 06 0 REFRAC 1/V YR VN-GR08 5 REFRAC 1/V YR VN-GR08 10 REFRAC 1/V YR VN-GR08 15 REFRAC 1/V YR VN-GR08 20 REFRAC 1/V YR VN-GR08 25 REFRAC 1/V YR VN-GR08 30 REFRAC 1/V YR VN-GR08 35 REFRAC 1/V YR VN-GR08 267 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV NV Plan / Benefit V8X VAA VAC VAD VAK VAN VAP VB6 VDA VDF VFP VFQ VG6 VGP VGQ VJQ VKP VMQ VN2 VNQ VP6 VPE VPK VPP VQC VQD VQF VQP VRR VSF VSQ VSX VU6 VVP VVQ VWP VWQ VZG WPR WPS WPT WQR WQS WQT WRR WRS WRT XAA YBD YBN Plan / Benefit Description 40 REFRAC 1/V YR VN-GR08 0/150A SH-VN05 NEP 0/125A GR-VN05 NEP 0/75A GR-VN05 NEP 15/150A SH-VN05 NEP 20/75A GR-VN05 NEP 1PR 1YR GR-VN05 25/150A 2 YRS SH-VN06 15/70A GR-VN07 15/125A 2YRS GR-VN07 0/75A 2YRS VN-GR08 0/125A 2YRS VN-GR08 25/75A VN-GR06 5/75A 2YRS VN-GR08 5/125A 2YRS VN-GR08 10/75A 2YRS VN-GR08 10/125A 2YRS VN-GR08 15/125A 2YRS VN-GR08 10/75A 2YRS GR-VN07 20/75A 2YRS VN-GR08 ADVANCE WELLNESS SH-WL06 RESERVED PFFS 0 BOEING VN-GR08 20/125A 2YRS VN-GR08 15/130A 1YR DLX VN-SH08 30/70A 2YRS VN-SH08 0/130A 2YRS VN-SH08 25/70A 2YRS VN-GR08 10/75A GR-VN07 0/130A 2YRS SH-VN07 30/70A 2YRS SH-VN07 15/130A 1YR DLX SH-VN07 15/75A 2YRS VN-GR06 15/75A 2YRS VN-GR08 25/75A 2YRS VN-GR08 25/125A 2YRS VN-GR08 25/70 2YRS VN-GR08 0/60A B-148 VN-GR08 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 NO RX GR05 MCC NYE DELUXE SH07 MC COMP NYE SH07 268 of 640 Plan Benefit - NV State NV NV NV NV NV NV NV Plan / Benefit YBP YFD YFN YFP Z2P Z2T Z8P Plan / Benefit Description MCC NYE PP SH07 MCC ESS NYE DELUXE SH07 MC COMP ESS NYE SH07 MCC ESS NYE PP SH07 10-15/50A T1A NON-AARP GR8 15-25/200D T3A NO-AARP GR8 10-20/200A T1C NO-AARP GR8 269 of 640 Plan Benefit - OK Cap/Eligibility CP7810 Assigned Plan Benefit Codes & Descriptions State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 0AZ 0BZ 1AZ 1BZ 1EZ 1JZ 1S2 1SA 1U5 1UA 1UB 201 271 2AN 2AY 2AZ 2BL 2BZ 2C1 2C2 2C3 2CF 2CG 2CH 2CJ 2CK 2CL 2CM 2CN 2CP 2FB 2FH 2FL 2G1 2G2 2G3 2G4 2GH 2HH 2JH 2KH 2MH Plan / Benefit Description PPO PLAN10 15 80/60 250 CB PPO PLAN10 15 80/60 250 CB PPO PLAN1 15 90/70 250 CBR PPO PLAN1 15 90/70 250 CBR PPO PLAN11 20 80/60 250 CB PPO PLAN11 20 80/60 250 CB $10G SH $5 $5 $10 $5 2070 PLAN 2070 PLAN 4/20/40 LO GR-RX07 4/25/50 HI GR-RX07 PPO PLAN2 20 90/70 250 CBR 10/25/50 RX-GR08 PPO PLAN2 20 90/70 250 CBR $5G/$10B $10G/$15B $7G/$15B $5G/$5B $5G/$5B $7G/$15 $5G/$15B FEDS RX $10G/$20B $5G/$10B $5G/$5B $5G/$10B 7/20 GEN MOTORS 5/10 RX06 4/15/30 RX-GR08 5/20/45 RX-GR08 $7G/$14B $10G/$20B $10G/$25B $10G/$20B 4/20/40 RX-GR08 4/15/30 RX-GR08 4/20/40 RX-GR08 4/25/50 RX-GR08 4/25/45 RX-GR08 270 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 2NH 2PH 2QH 2S1 2S4 2SA 2U1 2U2 2U5 2U6 2U7 2UB 2UF 2UH 2UJ 2VH 2WH 2XH 2YH 2Z1 2Z7 2ZA 2ZB 2ZC 2ZD 2ZE 2ZF 33B 3AC 3AZ 3B4 3BD 3BZ 3C1 3C2 3C3 3CF 3CH 3CL 3CM 3CT 3CU 3E1 3E2 3E3 3E4 3E5 3FA 3FC 3FD Plan / Benefit Description 4/28/55 RX-GR08 4/28/58 RX-GR08 4/25/50 RX-GR08 $10G/$30B SH $10G/$30B SH $5G/$15B $5G/$10B $5G/$15B $10G/$20B $10G/$25B $10G/$30B $5G/$15B $10G/$25B 10/25/50 RX-GR08 $5G/$15B 10/25/50 RX-GR08 5/20/45 RX-GR08 5/20/45 RX-GR08 4/10/20 RX-GR08 2070 PLAN (COBRA) 2070 PLAN (COBRA) 0/0 GR-RX07 2/40 GR-RX07 5/25 GR-RX07 5/65 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 5/15/30 BO RX-GR08 15/30/45 RX06 PPO PLAN3 10 90/70 250 CBR 5G/15B/30NF GRP RT 5/20/45 RX06 PPO PLAN3 10 90/70 250 CBR $10/$15/$25 $15/$20/$30 $10/$20/$30 $20G/$40B/$50NF $10G/$25B/$45NF $10G/$35B/$60NF $10/$35/$60 200D $10G/$20B/$40NF $10G/$25B/$40NF 10/20/45 E 10/30/50 E 15/25/50 E 15/30/50E 1HD 15/35/60E 2HD 10/30/50 RX06 10/40/50 RX05 15/30/60 RX06 271 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 3G1 3G2 3G3 3GA 3GB 3JP 3MR 3OA 3PB 3PC 3PH 3QT 3U5 3U7 3U8 3U9 3UG 3UI 3UL 3XB 3ZE 3ZF 3ZG 3ZH 3ZJ 3ZK 3ZL 3ZM 400 401 402 403 404 405 406 407 408 409 40A 40B 40C 40D 40E 40F 40G 40H 40I 40J 40K 40L Plan / Benefit Description $15G/$25B/$40NF $10G/$20B/$50NF $10G/$20B/$40NF $15G/$25B/$40NF 15G/25B/40NF W/INJ 10/25/40 JPMRGN 10/30/60 RX 08 $10G/$30B/$55NF 10/20/40 RX06 $10/$30/$40 PHS 10/30/50 RX06 10/20/35 RX 08 $5/$10/$25 $5/$15/$30 $5/$15/$35 $10/$20/$35 $5/$15/$30 $10/$20/$35 $10G/$15B/$25NF 5/20/35 RX 08 5/10/20 GR-RX07 10/20/35 GR-RX07 10/20/35 GR-RX07 10/25/55 GR-RX07 10/40/75 GR-RX07 7/20/50% GR-RX07 2/30/60 GR-RX07 10/25/50 GR-RX07 MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 272 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 40M 40N 40O 40P 40Q 40R 40S 40T 40U 40V 40W 40X 40Y 40Z 410 411 412 413 414 415 416 417 418 419 41A 41B 41C 41D 41E 41F 41G 41H 41I 41J 41K 41L 41M 41N 41O 41P 41Q 41R 41S 41T 41U 41V 41W 41X 41Y 41Z Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 273 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 420 421 422 423 424 425 426 427 428 429 42I 430 43I 440 44I 45I 46H 46I 46M 47I 48I 49I 4A0 4A1 4AI 4AO 4AZ 4B0 4B1 4BI 4BO 4BZ 4C0 4C1 4CI 4CO 4D0 4D1 4E0 4E1 4EI 4EO 4F0 4F1 4FI 4FO 4G0 4G1 4GI 4H0 Plan / Benefit Description MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO RESERVED RX PPO MANDATED OFFER RIDER PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO MCC OKCTY GR08 RESERVED RX PPO MCC OKCTY DLX GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO PPO PLAN4 20 90/70 500 CBR RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO PPO PLAN4 20 90/70 500 CBR RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 274 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 4H1 4HI 4HO 4I0 4I1 4IA 4IB 4IC 4ID 4IE 4IF 4IG 4IH 4II 4IJ 4IK 4IL 4IN 4IO 4IP 4IQ 4IR 4IS 4IT 4IU 4IV 4IW 4IX 4IY 4IZ 4J0 4J1 4JI 4JO 4K0 4K1 4KI 4KO 4L0 4L1 4LI 4M0 4M1 4MI 4MO 4N0 4N1 4NI 4NO 4O0 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 275 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 4O1 4OA 4OB 4OC 4OD 4OF 4OH 4OI 4OJ 4OK 4OL 4OM 4OO 4OP 4OQ 4OS 4OT 4OU 4OV 4OW 4OX 4OY 4OZ 4P0 4P1 4PI 4PO 4Q0 4Q1 4QI 4QO 4R0 4R1 4RO 4S0 4S1 4T0 4T1 4TI 4U0 4U1 4UI 4UO 4V0 4V1 4VI 4VO 4W0 4W1 4WI Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 276 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 4WO 4X0 4X1 4XI 4XO 4Y0 4Y1 4YI 4YO 4Z0 4Z1 4ZI 4ZO 50A 50B 50C 50D 50E 50F 50G 50H 50I 50J 50K 50L 50M 50N 50O 50P 50Q 50R 50S 50T 50U 50V 50W 50X 50Y 50Z 51A 51B 51C 51D 51E 51F 51G 51H 51I 51J 51K Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 277 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 51L 51M 51N 51O 51P 51Q 51R 51S 51T 51U 51V 51W 51X 51Y 51Z 52I 535 536 537 538 539 53I 540 541 542 543 544 545 546 547 548 549 54I 550 551 552 553 554 555 556 557 558 559 55I 560 561 562 563 564 565 Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 278 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 566 567 568 569 56I 570 571 572 573 574 575 576 577 578 579 57I 580 581 582 583 584 585 586 587 588 589 58I 590 591 592 593 594 59I 5A0 5A1 5AA 5AI 5AO 5AX 5AZ 5B0 5BA 5BI 5BO 5BX 5BZ 5C0 5C1 5CA 5CI Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO HMO 5 RESERVED BENEFIT PPO RESERVED BENEFIT PPO PPO PLAN5 15 80/60 500 CBR HMO 5 COBRA RESERVED BENEFIT PPO HMO 5 RESERVED BENEFIT PPO RESERVED BENEFIT PPO PPO PLAN5 15 80/60 500 CBR HMO 5 COBRA RESERVED BENEFIT PPO RESERVED BENEFIT PPO HMO 5 RESERVED BENEFIT PPO 279 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 5CO 5CZ 5D0 5D1 5E0 5E1 5EI 5F0 5F1 5FI 5FO 5G0 5G1 5GI 5H0 5H1 5HI 5HO 5I0 5I1 5IA 5IB 5IC 5ID 5IE 5IF 5IG 5IH 5II 5IJ 5IK 5IL 5IN 5IO 5IP 5IQ 5IR 5IS 5IU 5IV 5IW 5IX 5IY 5IZ 5J0 5J1 5JI 5JO 5K0 5K1 Plan / Benefit Description RESERVED BENEFIT PPO HMO 5 COBRA RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 280 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 5KI 5KO 5L0 5L1 5LI 5M0 5M1 5MI 5N0 5N1 5NI 5NO 5O0 5O1 5O2 5O3 5O4 5O5 5O6 5O7 5O8 5O9 5OA 5OB 5OD 5OF 5OH 5OI 5OJ 5OK 5OL 5OM 5ON 5OO 5OQ 5OS 5OT 5OU 5OV 5OW 5OX 5OY 5OZ 5P0 5P1 5PI 5PO 5Q0 5Q1 5QI Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 281 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 5QO 5R0 5RO 5S0 5S1 5S2 5S3 5SA 5SB 5SC 5T0 5T1 5TI 5U0 5U1 5UI 5UO 5V0 5V1 5VI 5VO 5W0 5W1 5WI 5WO 5X0 5X1 5XI 5XO 5Y0 5Y1 5YI 5YO 5Z0 5Z1 5ZI 5ZO 635 636 637 638 639 640 641 642 643 644 645 646 647 Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO HMO 5 SMALL GROUP COBRA HMO 5 SMALL GROUP COBRA HMO 5 SMALL GROUP COBRA HMO 5 SMALL GROUP HMO 5 SMALL GROUP HMO 5 SMALL GROUP RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 282 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 6AH 6AL 6AP Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 0/0 HI GR-RX07 0/0 LO GR-RX07 8.50/25.90/50% SH6 283 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 6AZ 6BH 6BL 6BP 6BZ 6DH 6DL 6EH 6EL 6EM 6FH 6FL 6FM 6FR 6HH 6HL 6JH 6JL 6KH 6KL 6LH 6LL 6MA 6MH 6ML 6NH 6NL 6PH 6PI 6PL 6PR 6QH 6QL 6QM 6RH 6RL 6SH 6SL 6SP 6TH 6TL 6UH 6UL 6VM 6WH 6ZM 6ZR 710 711 712 Plan / Benefit Description PPO PLAN6 20 90/70 500 CBR 2/30/60 HI GR-RX07 2/30/60 LO GR-RX07 8.50/25.90/50% SH6 PPO PLAN6 20 90/70 500 CBR 2/40 HI GR-RX07 2/40 LO GR-RX07 5/25 HI GR-RX07 5/25 LO GR-RX07 3/3 FLAT GR-RX06 5/65 HI GR-RX07 5/65 LO GR-RX07 3/3/3 GR-RX06 10/20 GR-RX06 5/10 HI GR-RX07 5/10 LO GR-RX07 5/10/20 HI GR-RX07 5/10/20 LO GR-RX07 7/14 HI GR-RX07 7/14 LO GR-RX07 7/20/50% HI GR-RX7 7/20/50% LO GR-RX7 10/25%/40% RX-GR06 10/20 HI GR-RX07 10/20 LO GR-RX07 10/20/40 HI GR-RX7 10/20/40 LO GR-RX7 10/20 HI GR-RX07 10/20/40 I GR-RX06 10/20 LO GR-RX07 10/20/40 GR-RX06 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 5/15/30 GR-RX06 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 10/25/55 HI GR-RX7 10/25/55 LO GR-RX7 4.45/14.50/50% SH6 10/40/75 HI GR-RX7 10/40/75 LO GR-RX7 15/25/40 HI GR-RX7 15/25/40 LO GR-RX7 5/5 GR-RX06 10/25/50 HI GR-RX7 7/14 GR-RX06 15/25/40 GR-RX06 RESERVED PPO RESERVED PPO RESERVED PPO 284 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 713 714 715 716 717 718 719 71A 71B 71C 71D 71E 71F 71G 71H 71I 71J 71K 71L 71M 71N 71O 71P 71Q 71R 71S 71T 71U 71V 71W 71X 71Y 71Z 720 721 722 723 724 725 726 727 728 729 72A 72B 72C 72D 72E 72F 72G Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 285 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 72H 72I 72J 72K 72L 72M 72N 72O 72P 72Q 72R 72S 72T 72U 72V 72W 72X 730 731 732 733 734 735 736 737 738 739 73A 73B 73C 73D 73E 73F 73G 73H 73I 73J 73K 73L 73M 73N 73O 73P 73Q 73R 73S 73T 73U 73V 73W Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 286 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 73X 73Y 73Z 740 741 742 743 744 745 746 747 748 749 74A 74B 74C 74D 74E 74F 74G 74H 74I 74J 74K 74L 74M 74N 74O 74P 74Q 74R 74S 74T 74U 74V 74W 74X 74Y 74Z 750 751 752 753 754 755 756 757 758 759 75A Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO 287 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 75B 75C 75D 75E 75F 75G 75H 75I 75J 75K 75L 75M 75N 75O 75P 75Q 75R 75S 75T 75U 75V 75W 75X 75Y 75Z 760 761 762 763 764 765 766 767 768 769 76A 76B 76C 76D 76E 76F 76G 76H 76I 76J 76K 76L 76M 76N 76O Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 288 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 76P 76Q 76R 76S 76T 76U 76V 7AQ 7AR 7AZ 7BD 7BH 7BI 7BL 7BR 7BZ 7CD 7CI 7CM 7DD 7DH 7DL 7DM 7DR 7ED 7EH 7EL 7EM 7ER 7FD 7FH 7FL 7FM 7FR 7GD 7GM 7GR 7HH 7HI 7HL 7HR 7JH 7JL 7JM 7JR 7KH 7KI 7KL 7KM 7KR Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 7/20 GR-RX07 0/0 GR-RX07 PPO PLAN7 10 80/60 500 CBR 7/14 GR-RX07 4/10/20 T1A H GRX7 7/14 I GR-RX07 4/10/20 T1A L GRX7 0/0 FLAT GR-RX07 PPO PLAN7 10 80/60 500 CBR 7/14 GR-RX07 7/14 I GR-RX07 15/25/40 GR-RX07 7/20/30 GR-RX07 4/15/30 T1B H GRX7 4/15/30 T1B L GRX7 15/25/40 GR-RX07 10/10 FLAT GR-RX07 7/7 GR-RX07 4/20/40 T1C H GRX7 4/20/40 T1C L GRX7 3/3 FLAT GR-RX07 10/20 GR-RX07 7/7 C GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 3/3/3 GR-RX07 10/20 GR-RX07 10/20/30 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 4/15/30 T2A H GRX7 10/20 I GR-RX07 4/15/30 T2A L GRX7 10/20 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/10 GR-RX07 10/10 GR-RX07 4/28/55 T3B H GRX7 10/20/35 I GR-RX07 4/28/55 T3B L GRX7 5/10/20 GR-RX07 10/20/35 GR-RX07 289 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 7LH 7LL 7LM 7LR 7MA 7MH 7MI 7ML 7MR 7NH 7NL 7NM 7PH 7PI 7PL 7PM 7PR 7QH 7QI 7QL 7QM 7QR 7RA 7RB 7RC 7RD 7RH 7RL 7RM 7SB 7SI 7SR 7TH 7TL 7TM 7TR 7UH 7UL 7UM 7UR 7VH 7VL 7VM 7WH 7WI 7WL 7WM 7WR 7XA 7XB Plan / Benefit Description 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 5/15 GR-RX07 15/25/40 GR-RX07 10/25%/40% GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 10/20/40 GR-RX07 4/25/50 T2C H GRX7 4/25/50 T2C L GRX7 5/15/30 GR-RX07 4/25/50 T2C H GRX7 10/20/40 I GR-RX07 4/25/50 T2C L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 4/15/30 T2A H GRX7 4/15/30 T2A L GRX7 5/15/30 GR-RX07 10/25%/40% GR-RX07 10/20/40 I GR-RX07 10/20/40 GR-RX07 4/28/55 T3B H GRX7 4/28/55 T3B L GRX7 5/5 GR-RX07 10/25/40 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/5 GR-RX07 15/25/40 GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 5/5 GR-RX07 4/20/40 T1C H GRX7 15/25/40 I GR-RX07 4/20/40 T1C L GRX7 5/7.50 GR-RX07 15/25/40 GR-RX07 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 290 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 7XC 7XD 7XE 7XF 7XG 7XH 7XJ 7XL 7XM 7XP 7XV 7YH 7YI 7YL 7YM 7YR 7ZH 7ZL 7ZM 7ZR 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 82A 82B 82C 82D 82E 82F 82G 82H 82J 82K Plan / Benefit Description 4/20/40 RDS GR-RX7 4/25/50 RDS GR-RX7 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/15/30 T1B H GRX7 4/25/50 RDS GR-RX7 4/15/30 T1B L GRX7 7/14 GR-RX07 5/29/60 N/G SH-RX7 5/35/65 NGB SH-RX7 4/10/20 T1A H GRX7 15/25/40 I GR-RX07 4/10/20 T1A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 291 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 82L 82M 82N 82P 82Q 82R 82S 82T 82U 82V 82W 82X 82Y 82Z 830 831 832 833 834 835 836 837 838 839 83A 83B 83C 83D 83E 83F 83G 83H 83J 83K 83L 83M 840 841 842 843 844 845 846 847 848 849 84A 84B 84C 84D Plan / Benefit Description 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 292 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 84E 84F 84G 84H 84J 84K 84L 84M 84N 84P 84Q 84R 84S 84T 84U 84V 84W 84X 84Y 84Z 850 851 852 853 854 855 856 857 858 859 85A 85B 85C 85D 85E 85F 85G 85H 85J 85K 85L 85M 860 861 862 863 864 865 866 867 Plan / Benefit Description 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 293 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 868 869 870 881 882 88F 8AH 8AR 8AZ 8B8 8BH 8BZ 8CH 8DD 8DH 8DR 8ED 8EH 8EM 8ER 8FD 8FH 8GH 8GM 8HD 8HH 8K8 8KM 8LH 8LM 8M8 8MA 8NM 8PH 8PM 8R8 8RH 8RM 8SH 8TH 8TM 8TR 8UM 8UR 8VM 8WH 8Z1 8Z2 8ZF 910 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED FOR PPO 880 PLAN 880 PLAN OPT PLAN 880 0/0 HI C GR-RX07 0/0 C GR-RX07 PPO PLAN8 20 80/60 500 CBR 5/29/60NG RX-SH08 DO NOT USE PPO PLAN8 20 80/60 500 CBR 2/30/60 HI C GRX07 7/20/30 C GR-RX07 2/40 HI C GR-RX07 10/10 FLAT C GRX07 7/7 C GR-RX07 5/25 HI C GR-RX07 3/3 FLAT C GR-RX07 10/20 C GR-RX07 7/7 C GR-RX07 5/65 HI C GR-RX07 5/10 HI C GR-RX07 5/10 C GR-RX07 10/20/30 C GR-RX07 DO NOT USE 5/34/79NG RX-SH08 5/10/20 C GR-RX07 7/20/50% HI C GRX7 5/15 C GR-RX07 5/36/82NG RX-SH08 10/25%/40% C GRX07 5/15/30 C GR-RX07 10/20 HI C GR-RX07 5/15/30 C GR-RX07 5/37/71G RX-SH08 10/20/35 HI C GRX7 5/15/30 C GR-RX07 10/25/55 HI C GRX7 10/40/75 HI C GRX7 5/5 C GR-RX07 10/25/40 C GR-RX07 5/5 C GR-RX07 15/25/40 C GR-RX07 5/7.50 C GR-RX07 10/25/50 HI C GRX7 880 PLAN (COBRA) 880 PLAN OPT PLAN 880 (COBRA) RESERVED PPO 294 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 911 912 913 914 915 916 917 918 919 91H 920 921 922 923 924 925 926 927 928 929 92H 930 931 932 933 934 935 936 937 938 939 93H 940 941 942 943 944 945 946 947 948 949 94H 950 951 952 953 954 955 956 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15/25/40 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/25/50 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20/40 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20 HI RX-GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 295 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 957 958 959 95H 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 9AN 9AQ 9AR 9AY 9AZ 9BE 9BH 9BL 9BZ 9CM 9DH Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO 10/40/75 HI C XGR8 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 4/20/40 LO RX-GR08 7/20 RX-GR08 0/0 RX-GR08 4/25/50 HI RX-GR08 PPO PLAN9 25 80/60 500 CBR 7/14 RX-GR08 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 PPO PLAN9 25 80/60 500 CBR 15/25/40 RX-GR08 4/15/30 T1B H XGR8 296 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 9DL 9DR 9EH 9EL 9ER 9FD 9FH 9FL 9GE 9GM 9HD 9HH 9HK 9HL 9HN 9JH 9JL 9KH 9KL 9KS 9LH 9LL 9LM 9LP 9LV 9MA 9MH 9MI 9ML 9MR 9NH 9NL 9NM 9PH 9PL 9PX 9QH 9QL 9RH 9RL 9RP 9RX 9TH 9TL 9UH 9UL 9VH 9VL 9VM 9WH Plan / Benefit Description 4/15/30 T1B L XGR8 10/10 FLAT C XGR08 4/20/40 T1C H XGR8 4/20/40 T1C L XGR8 10/20 RX-GR08 7/7 C RX-GR08 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 10/20/30 RX-GR08 5/10 RX-GR08 10/20/30 C RX-GR08 4/15/30 T2A H XGR8 4/10/20 RX-GR08 4/15/30 T2A L XGR8 4/15/30 RX-GR08 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 10/20/35 RX-GR08 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 5/15 C RX-GR08 5/15 RX-GR08 10/20/35 RX-GR08 10/25%/40% RX-GR08 4/20/40 T2B H XGR8 10/20/40 I RX-GR08 4/20/40 T2B L XGR8 10/20/40 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/15/30 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/29/60 P RX-GR08 4/20/40 T2B H XGR8 4/20/40 T2B L XGR8 4/15/30 T2A H XGR8 4/15/30 T2A L XGR8 5/15/30 RX-GR08 NO RX 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 5/5 RX-GR08 4/20/40 T1C H XGR8 297 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit 9WI 9WL 9WM 9XH 9XL 9YH 9YL 9ZH 9ZL A1C A1H A1L A1M A1X A1Z A38 AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AAA AAC AAF AAH AAJ AAZ AB1 ABA ABC ABZ ACA ACF ACZ AD0 AD1 AD2 AD3 AD4 AD5 AD8 ADA ADC ADH ADL ADM ADN Plan / Benefit Description 15/25/40 I RX-GR08 4/20/40 T1C L XGR8 5/7.50 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 PREFERRED PLAN PREFERRED PLAN COBRA PREFERRED PLAN PREFERRED PLAN PREFERRED PLAN COBRA PREFERRED PLAN COBRA C80 PLAN AA $15-$20/$250 AA $15-$20/$250 COBRA AA $15-$20/$250 AA $15-$20/$250 COBRA AA 20-40/250A AA 20-40/250A COBRA AA 20-40/250A AA 20-40/250A COBRA HMO 10 SV 20-40/350A 06 SV 20-40/350A 06 CB SV 20-40/350A 06 SV 20-40/350A 06 CB HMO 10 COBRA ANHEUSER-BUSCH $8/80 CBRA HMO 10 ANHEUSER-BUSCH $8/80 HMO 10 COBRA HMO 10 BROKER/CONSULTANT FEE HMO 10 COBRA ALCOHOL/DRUG ABUSE (100%) INP CHEM DEP-HIGH (STATE) INP CHEM DEP-LOW OK STATE INP CHEM DEP-LOW OK STATE INP CHEM DEP-HIGH OK STATE ALCOHOL/DRUG REHAB 50/50 ALCOHOL/DRUG ABUSE (80%) CHEMICAL DEPENDENCY (AAON) HMO 10 HILLCREST ALCOHOL/DRUG REHAB-HIGH ALCOHOL / DRUG REHAB -LOW ALCOH/DRUG REHAB - MC DOUG ADMINISTRATION FEE 298 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit ADS ADZ AEC AEZ AFM AFS AFX AL1 AL2 ALA ALB AMC AMH AML AMZ AN1 AN2 AN6 AN7 ANA ANB ANC AND ANE APF APN ART AS0 AS1 AS2 AS3 ASA ASB ASC ASD ASE AT7 ATP ATU ATV B2A B2B B2C B2D B2E B2F B2G B2H B2J B2P Plan / Benefit Description ALCOHOL/DRUG REHAB HMO 10 HILLCREST HMO 10 HILLCREST HMO 10 HILLCREST FORD MOTOR COMPANY ADMINISTRATIVE SERVICE FEE FORD MOTOR COMPANY - COBRA HMO LARGE GRP $15/90% CBR HMO LARGE GRP $15/90% CBR HMO LARGE GROUP $15/90% HMO LARGE GROUP $15/90% FORD MOTOR COMPANY MCDONNEL DOUGLAS PLAN MCDONNELL DOUGLAS PLAN FORD MOTOR COMPANY-(COBRA) AMERICAN AIR $10/$100 CBRA AMERICAN AIR $10/$100 CBRA SV $20-$40/$250A AM AIR CB SV $20-$40/$250A AM AIR CB AMERICAN AIRLINES $10/$100 AMERICAN AIRLINES $10/$100 SV $20-$40/$250A AM AIR ADMINISTRATION FEE SV $20-$40/$250A AM AIR 10/12V 1YR ACU SH07 10/12V 1YR ACU SH08 RESERVED ALLERGY SERUM ALLERGY SERUM (50%) ALLERGY SERUM ALLERGY SERUM ALLERGY SERUM ALLERGY SERUM ALLERGY SERUM $12/6 WEEKS ALLERGY SERUM $26/6WEEKS ALLERGY SERUM $12/6WEEKS ATW-STD SH-WL07 ATW-PLUS SH-WL07 ATW-PLUS WL-SH08 ATW-STD WL-SH08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 299 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit B2R B3A B3B B3C B3D B3E B3F B3G B3H B3J B3P B3R B4A B4B B4C B4D B4E B4F B4G B4H B4J B4P B4R B5A B5B B5C B5D B5E B5F B5G B5H B5J B5P B5R B62 B6A B6B B6C B6D B6E B6F B6G B6H B6J B6R B7A B7B B7C B7D B7E Plan / Benefit Description RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO 20-30/100% BH06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 300 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit B7F B7G B7H B7J B7P B7R B8A B8B B8C B8D B8E B8F B8G B8H B8J B8P B8R B9A B9B B9C B9D B9E B9F B9G B9H B9J B9P B9R BA1 BA2 BA3 BAC BAF BAH BBP BC0 BC1 BC2 BC3 BC4 BC5 BC6 BC7 BC8 BC9 BCA BCB BCC BCD BCE Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO BASIC PLAN BASIC PLAN RESERVED RESERVED OPT BASIC PLAN 25/250A BH 08 20/100D BH06 AMERICAN AIR SMI/MH/CD BOEING HOURLY SMI/MH/CD BOEING NUS SMI/MH/CD WILLIAM SONOMA SMI/MH/CD 7-ELEVEN SMI/MH/CD PACIFICARE SMI/MH/CD SMI/CHEM/MEN HLTH - MCKSN SMI/CHEM/MEN HLTH - PBG SMI/CD/MH BOEING VEBA SMI/MH/CD GM SALARIED STATE OK HIGH SMI/MH/CD STATE OK LOW SMI/MH/CD SEARS SMI/MH/CD $250 OK AA $15-$20/$250 OK MARRIOTT $15-$25/$100 301 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit BCF BCG BCH BCI BCJ BCK BCL BCM BCN BCO BCP BCQ BCR BCS BCT BCU BCV BCW BCX BCY BCZ BD2 BDA BDF BDK BDL BDN BE1 BE2 BEA BEB BEF BEK BFC BFD BFK BG6 BGF BGK BGR BH2 BH3 BH4 BH5 BH6 BH7 BH8 BH9 BHA BHB Plan / Benefit Description PEPSI BOTTLING $20/$200 LOCKHEED $20/100% CHEVRON TEXACO $20/100% FARMERS $15-$30/$250 GM SALARIED $15/100% AT&T $10-$15/$100 GM HOURLY 2003 $10/100% BOEING $10/100% HOURLY BOEING $10/100% IAM ORAL ROBERTS $20/NC FORD $0/100% FORD SALARY $0/100% BOEING $15/100% NORTHROP GRUMMAN 100%/$20 OK SMI/MH/CD HI OPTION STATE FARM SMI/MH/CD BANK ONE SMI/MH/CD PBG SMI/MH/CD SMI/CD/MH BOEING IAM OK SMI/MH/CD LOW OPTION OK SMI/MH/CD ALT OPTION 15-20/100A BH06 0/250A BOEING IAM725 GR 06 0/250A BOEING IAM725 GR 06 SV 15/250A BOEING 08 0 BO IAM 725 NO-AARP GR08 0 BO IAM 725 NO-AARP GR08 SV 15/200A BOEING UAW CB SV 15/200A BOEING UAW CB SV 15/200A BOEING UAW SV 15/200A BOEING UAW 15/250A BH 08 SV 15/250A BOEING 08 CB SV 15/250A BOEING 08 SV 15/250A BOEING 08 CB SV 15/250A BOEING 08 20-50/500D OK MH06 20-40/250D BH 06 SV 15/250A BOEING 08 CB 25-40/500A BH 08 BOEING NA-HRLY $10 GRP RET BOEING NA-HRLY $10 GRP RET BOEING HOURLY $15 GRP RET BOEING HOURLY $15 GRP RET 20-35/200A OK MH06 $15/$200 BOEING GR $15/$200 BOEING GR 35/240A MH06 NA SMI/CD/MH $10/$20/$100D NA SMI/CD/MH $15/$30/$250D 302 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit BHC BHD BHE BHG BHH BHJ BHK BHL BHM BHN BHP BHQ BHR BHS BHT BHU BHV BHW BHX BHY BHZ BIE BIF BIG BIH BJC BJP BKP BKR BL1 BL2 BLA BLB BNE BNF BNG BNH BO1 BO2 BO3 BO4 BO5 BO6 BO7 BO8 BOA BOB BOC BOD BOE Plan / Benefit Description NA SIM/CD/MH $15/$30/$400D NA SMI/CD/MH $20/$40/$250D NA SMI/CD/MH $20/$40/$400D RE SMI/CD/MH $20/$40/$250D 20-40/200A BH 06 NA SMI/CD/MH $5/100% NA SMI/CD/MH $10/100% NA SMI/CD/MH $10/$100 NA SMI/CD/MH $10/$250 NA SMI/CD/MH $15/$100 NA SMI/CD/MH $15/$250 RE SMI/CD/MH $5/100% RE SMI/CD/MH $10/100% RE SMI/CD/MH $15/10% RE SMI/CD/MH $20/100% RE SMI/CD/MH $20/$400 RE SMI/CD/MH $20/20% RE SMI/CD/MH $25/$600 NA SMI/CD/MH $15/100% NA SMI/CD/MH $10/$15/$250 20-40/350A BH 06 SV 15/200A BOEING IAM SV 15/200A BOEING IAM CB SV 15/200A BOEING IAM SV 15/200A BOEING IAM CB 20-40/250A BH 07 SV 15/250A BOEING 08 SV 15/250A BOEING 08 CB 15/250A BH06 HMO LARGE GRP $20/$400 CBR HMO LARGE GRP $20/$400 CBR HMO LARGE GROUP $20/$400 HMO LARGE GROUP $20/$400 SV 10/100% BOEING NUS SV 10/100% BOEING NUS CB SV 10/100% BOEING NUS SV 10/100% BOEING NUS CB BOEING HRLY $10/100% BOEING HRLY $10/100% COBRA BOEING HRLY $10/100% BOEING HRLY $10/100% COBRA BOEING HRLY $15/100% BOEING HRLY $15/100% COBRA BOEING HRLY $15/100% BOEING HRLY $15/100% COBRA BOEING ERET $15/100% BOEING ERET $15/100% COBRA BOEING ERET $15/100% BOEING ERET $15/100% COBRA SV 15-25/250A BOEING 303 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit BOF BOG BOH BOR BOS BP2 BP3 BP4 BP5 BP6 BP7 BP8 BP9 BPA BPC BPD BPE BPF BPG BPH BPJ BPK BPL BPM BPN BPP BPQ BPR BPS BPU BPV BPW BPX BPY BPZ BQ1 BQ2 BQ3 BQ4 BQ5 BQ6 BQ7 BQ8 BQA BQB BQC BQD BQE BQF BQG Plan / Benefit Description SV 15-25/250A BOEING CB SV 15-25/250A BOEING SV 15-25/250A BOEING CB 15 BO 148 NO-AARP GR08 15 BO 148 NO-AARP GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20/40/250D SG SV 20/40/250D SG CB SV 25/600A SG SV 25/600A SG CB SV 20/400A SG SV 20/400A SG CB SV 10/200A SG SV 10/200A SG CB SV 20/40/250D SG SV 20/40/250D SG CB SV 25/600A SG SV 25/600A SG CB SV 20/400A SG SV 20/400A SG CB SV 10/200A SG 304 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit BQH BQI BQJ BQK BQL BQM BQN BQP BQQ BR2 BR3 BR4 BR5 BR6 BR7 BR8 BR9 BRA BRH BS1 BS2 BS3 BSA BSB BSC BSD BSE BSF BSG BSH BSI BSJ BSK BSL BSM BU1 BU2 BU3 BU4 BU5 BU6 BU7 BU8 BU9 BUC BUD BUE BUF BUG BUH Plan / Benefit Description SV 10/200A SG CB SV 20/20% SV 20/20% CB SV 20/20% SV 20/20% CB SV 20-40/250D SV 20-40/250D CB SV 20-40/250D SV 20-40/250D CB RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 20-40/250D BH 07 15/250A BH 08 HMO 10 SMALL GROUP COBRA HMO 10 SMALL GROUP COBRA HMO 10 SMALL GROUP COBRA HMO 10 SMALL GROUP HMO 10 SMALL GROUP HMO 10 SMALL GROUP SG CD/MH $10/$200 SG CD/MH $15/$300 SG CD/MH $20/$400 SG CD/MH $25/$600 SG CD/MH $20/$40/$250D SG CD/MH $10/$200 SG CD/MH $15/$300 SG CD/MH $20/$400 SG CD/MH $25/$600 SG SMI/CD/MH $20/$40/$250D RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO 305 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit BUI BUJ BUK BUL BUM BUN BUO BUP BUQ BUR BUS BUT BUU BUV BUW BUX BUY BUZ BVE BVG BVK BVL BVN BX2 BX3 BX4 BX5 BX6 BX7 BX8 BX9 BXA BXB BXC BXD BXE BXF BXG BXH BXJ BXK BXL BXM BXN BXP BXR BXS BXT BXU BXV Plan / Benefit Description RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO SMI/CD/BH $10/$20/$100 SMI/CD/BH $15/$30/$250 SMI/CD/BH $15/$30/$400 SMI/CD/BH $20/$40/$250 SMI/CD/BH $20/$40/$400 NA SMI/CD/MH $5/100% NA SMI/CD/MH $10/100% NA SMI/CD/MH $10/$100 NA SMI/CD/MH $10/$250 NA SMI/CD/MH $15/100% NA SMI/CD/MH $15/$100 NA SMI/CD/MH $15/$250 15/100A BOEING VEBA GR07 25/240A BH07 15/100A BOEING VEBA GR07 15 BO-VEBA NON-AARP GR08 15 BO-VEBA NON-AARP GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 306 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit BXW BXX BXY BXZ BYA BYB BYC BYD BYE BYF BYG BYH BYJ BYK BYL BYM BYN BYP BYR BYS BZ1 BZ2 BZ3 BZ4 BZ5 BZ6 BZ7 BZ8 BZ9 BZA BZB BZC BZD BZE BZF BZG BZH BZJ BZK BZL BZM BZN BZP BZR BZS BZT BZV BZW BZX BZY Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO BASIC PLAN (COBRA) BASIC PLAN (COBRA) RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO OPT BASIC PLAN (COBRA) RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 307 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit BZZ C1C C1H C1L C1M C1X C1Z C27 C7A C7E C7F C7G C7H C7J C7K C7L C7M C7P C7S C7U C7W C7Y CD1 CD5 CD8 CDA CDB CDC CDD CDE CDF CDG CDH CDI CDJ CDP CDQ CDR CDS CDT CDU CDV CDW CEO CF1 CF2 CF3 CFA CFC CFD Plan / Benefit Description RESERVED RX PPO STANDARD PLAN STANDARD PLAN COBRA STANDARD PLAN STANDARD PLAN STANDARD PLAN COBRA STANDARD PLAN COBRA SC 90 ELIGIBILITY ONLY 5/12V 1YR GR-CH07 10/12V 1YR GR-CH07 10/20V 1YR GR-CH07 10/30V 1YR GR-CH07 15/12V 1YR GR-CH07 15/20V 1YR GR-CH07 0/20V 1YR GR-CH07 15/30V 1YR GR-CH07 20/12V 1YR GR-CH07 5/10V 1YR GR-CH07 30/12V 1YR GR-CH07 5/20V 1YR GR-CH07 5/30V 1YR GR-CH07 5/40 1YR GR-CH07 CHEM DEP-STANDARD EFF 1-99 CHEM DEP IP/100% OP COPAY CHEMICAL DEPENDENCY - 80% CHEM DEP IP/100% OP COPAY CHEM DEP IP/$250 OP $15 CD OPOV/40VISIT IP100% CST CD $15OV/30VISIT IP$50030D CD FEDS IP100% OP$20WLIMIT CHEM DEP - I/P 100% CHEM DEP - I/P 90% CHEM DEP - I/P 80% CHEM DEP - I/P $150 CHEM DEP IP $250 OP $20 CHEM DEP-I/P $200 CHEM DEP-I/P $300 CHEM DEP-I/P $400 CHEM DEP-I/P $600 CHEM DEP-I/P 90% CHEM DEP-I/P 80% CHEM DEP-I/P $100 CD I/P $250 15/30V CH 07 RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO FEDERAL EMPLOYEE PLAN RESERVED FOR RX PPO 308 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit CFE CFF CFL CFM CG8 CG9 CGG CGI CGL CGP CGR CGS CGU CGV CGX CH5 CHA CHB CHC CHD CHE CHF CHG CHH CHL CHM CHQ CHU CHW CHX CIC CIL CIM CJC CJL CJM CKC CKD CKE CKF CKM CKN CL1 CL2 CLA CLB CMH CMJ CML CN4 Plan / Benefit Description RESERVED FOR RX PPO RESERVED FOR RX PPO FEDERAL EMPLOYEE PLAN FEDERAL EMPLOYEE PLAN 10/20V CH 07 15/20V CH 07 CAREGIVER-SH GOLD CAREGIVER-SH INDIV CAREGIVER LITE SH06 CAREGIVER PROGRAM CAREGIVER-RESPITE SH07 CAREGIVER PROGRAM CAREGIVER-RESPITE CG-SH08 CAREGIVER CG-GR08 CAREGIVER ENHANCED CHIRO-STATE OF OK. HIGH CHIRO-STATE OF OK. LOW CHIRO $20/15 ST OF OK-LOW FEDERAL EMPLOYEES PLAN-FEH CHIRO $10/15 ST OF OK-HIGH CHIRO $5/10 VISITS CHIRO $10/10 VISITS CHIRO $15/10 VISITS CHIRO $30/15 ST OF OK-LOW FEDERAL EMPLOYEES PLAN-FEH FEDERAL EMPLOYEES PLAN-FEH FEDS 20/20V ACU/CHIRO 05 10/12V 1YR SH-CH07 10/12V 1YR SH-CH08 15/10V CH 07 FEDERAL EMPLOYEES PLAN1-99 FEDERAL EMPLOYEES PLAN1-99 FEDERAL EMPLOYEES PLAN1-99 FEDS $10 CUSTOM EFF 1-00 FEDS $10 CUSTOM EFF 1-00 FEDS $10 CUSTOM EFF 1-00 FEDS 2001 FEDS 2003 FEDS 2004 FEDS 2004 FEDS 2001 FEDS 2003 HMO LARGE GRP $20/80% CBR HMO LARGE GRP $20/80% CBR HMO LARGE GROUP $20/80% HMO LARGE GROUP $20/80% CHEMICAL/MENTAL -LDDS HIGH SV 25/250A CHEV-TEX 08 CHEMICAL/MENTAL LDDS LOW 5/30V CH 07 309 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit CN9 CPA CQ1 CQ8 CQJ CR3 CR4 CR5 CR6 CRG CRP CRX CRY CS1 CS2 CS8 CSA CSB CSH CSL CT1 CT2 CT3 CT4 CT5 CUJ CV1 CV2 CV3 CV4 CVA CVB CVC CVD CWJ CXH D00 D02 D10 D1C D1G D1H D1K D1L D1M D1U D1V D1X D1Z D20 Plan / Benefit Description FEDS 20/20V ACU/CHIRO 07 RESERVED PFFS 10/30V CH 07 20/15V CH - ST OF OKLA 07 SV 25/250A CHEV-TEX 08 CB GRP RET CHIRO $5/12VISITS GRP RET CHIRO $10/12VISITS GRP RET CHIRO $15/12VISITS GRP RET CHIRO $20/12VISITS CUSTOM PPO $5G/$25BR RETIREE $10G/$25B 1500 ANN.MAX. RESERVED FOR RX PPO $10/250 CENTRAL & SW COBRA $10/250 CENTRAL & SW COBRA INPAT CHEM DEP (ST OF OK) $10/250 CENTRAL-SOUTHWEST $10/250 CENTRAL-SOUTHWEST STATE OF OKLAHOMA STATE OF OKLAHOMA NAT'L CHIRO $10/20 VISITS NAT'L CHIRO $15/20 VISITS NAT'L CHIRO $15/30 VISITS NAT'L CHIRO $5/30 VISITS NAT'L CHIRO $10/30 VISITS SV 25/250A CHEV-TEX 08 CHEVRON TEX $20/100% CHEVRON TEX $20/100% COBRA CHEVRON TEX $20/100% CHEVRON TEX $20/100% COBRA SV 20/100% W/BU CHEVRON SV 20/100% W/BU CHEVRON CB SV 20/100% W/BU CHEVRON SV 20/100% W/BU CHEVRON CB SV 25/250A CHEV-TEX 08 CB DONOT USE/FOR CA USE DURABLE MED EQUIP DME 10% (LDDS) DURABLE MEDICAL EQUIPMENT STANDARD 5 PLAN KP100 CTANDARD 5 PLAN COBRA KP100 STANDARD 5 PLAN STANDARD 5 PLAN KP100 KP100 STANDARD 5 PLAN COBRA STANDARD 5 PLAN - COBRA DURABLE MED EQUIP 20% 310 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit D2C D2Z D6V D8A D8E D8L DBA DE6 DFC DFM DFX DFZ DGC DGZ DHC DHZ DIR DL1 DL2 DLA DLB DMC DMH DML DMM DMX DMZ DN2 DN3 DNE DNT DNY DO2 DP1 DPA DPB DPC DQ6 DS1 DS2 DSA DSB DZC DZZ E2O E3O E4O E5O EC6 EL1 Plan / Benefit Description STANDARD 5100 HILLCREST STD 5100 COBRA HILLCREST DENTAL - VISION GR06 DELUXE OPTION DN-SH08 $20 469 DN-SH08 $0 466 DN-SH08 100%/70% DISCOUNT GR-DN07 $0 466 SH-DN06 FORD MOTOR CREDIT PLAN FORD MOTOR CREDIT CO PLAN FORD MOTOR CREDIT CO COBRA FORD MOTOR CREDIT CO.COBRA NORTHROP GRUMAN PLAN NORTHROP GRUMAN PLAN COBRA NORTHROP GRUMAN PLAN NORTHROP GRUMAN PLAN COBRA DUMMY-USED FOR VRU CODING HMO LARGE GRP $25/$600 CBR HMO LARGE GRP $25/$600 CBR HMO LARGE GROUP $25/$600 HMO LARGE GROUP $25/$600 MCDONNELL DOUGLAS PLAN MCDONNELL DOUGLAS PLAN MCDONNELL DOUGLAS PLAN MCDONNELL DOUGLAS PLAN MCDONNELL DOUGLAS PLAN CBR MCDONNELL DOUGLAS PLAN CRB PPO 460 GRP BILLED - GR PPO 462 INDIV BILLED -GR EVERCARE $5 SH-DN07 PREVENTIVE DENTAL PLAN DELUXE OPTION SH-DN07 OK SH OPT DENTAL DEPENDENT LIFE BENE SAME SEX DOMESTIC PARTNER OPPOSITE DOMESTIC PARTNER DOMESTIC PARTNER SAME/OPPO $20 469 SH-DN06 SMALL GRP HMO $10/$200 CBR HMO SMALL GRP $10/$200 CBR HMO SMALL GROUP $10/$200 HMO SMALL GROUP $10/$200 DUMMY CODE DUMMY CODE EVERCARE OKCTY DH-D SH08 EVERCARE TULSA DH-D SH08 EVERCARE OKCTY MH-D SH08 EVERCARE TULSA MH-D SH08 EVERCARE OKCTY DH SH07 HMO LARGE GRP $20/100% CBR 311 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit EL2 ELA ELB EOA EOD EOE EOF EOG EOH ES1 ES2 ESA ESB ETK ETM ETP EXO EYO EZO F01 F02 F03 F04 F05 F06 F07 F08 F09 F10 F11 F12 F13 F14 F15 F16 F17 F18 F19 F1B F1C F1F F1G F1H F1K F1L F1M F1P F1R F1S F1T Plan / Benefit Description HMO LARGE GRP $20/100% CBR HMO LARGE GROUP $20/100% HMO LARGE GROUP $20/100% EVERCARE OKCTY DH SH08 EVERCARE TULSA DH SH08 EVERCARE OKCTY IH SH08 EVERCARE TULSA IH SH08 EVERCARE OKCTY MH SH08 EVERCARE TULSA MH SH08 HMO SMALL GRP $15/$300 CBR HMO SMALL GRP $15/$300 CBR HMO SMALL GROUP $15/$300 HMO SMALL GROUP $15/$300 USED IN TX USED IN TX USED IN TX USED IN TX EVERCARE CC MH-D SH08 USED IN TX LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO KP100 ($10 OV) STANDARD 10 PLAN KP100 ($10 OV) COBRA KP100 ($10 OV) STANDARD 10 PLAN COBRA KP100 ($10 OV) STANDARD 10 PLAN STANDARD 10 PLAN STANDARD 10 PLAN (OPT) STANDARD 10 OPT PLAN STANDARD 10 OPT PLAN STANDARD 10 OPT PLAN COBRA 312 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit F1U F1V F1W F1X F1Y F1Z F20 F21 F22 F23 F24 F25 F26 F27 F28 F29 F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43 F44 F45 F46 F47 F48 F49 F50 F51 F52 F53 F54 F55 F56 F57 F58 F59 F60 FA2 FA3 FA4 Plan / Benefit Description KP100 ($10 OV) COBRA KP100 ($10 OV) COBRA STANDARD 10 OPT PLAN COBRA STANDARD 10 PLAN COBRA STANDARD 10 OPT PLAN COBRA STANDARD 10 PLAN COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO AT&T NATL $10-$15/$100 AT&T NATL $10-$15/$100 CBR AT&T NATL $10-$15/$100 313 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit FA5 FA6 FA7 FA8 FA9 FB3 FB5 FB6 FB7 FBA FBH FBJ FC8 FC9 FCA FCB FCD FCE FCF FCI FCJ FCL FCM FCN FD1 FD2 FD3 FD4 FD6 FD7 FD8 FD9 FDA FDB FE1 FE2 FFF FH6 FID FJ3 FJ4 FJ5 FJ6 FKF FM1 FM3 FM5 FM7 FM8 FMH Plan / Benefit Description AT&T NATL $10-$15/$100 CBR SV 10/15/100A W/BU AT&T SV 10/15/100A W/BU AT&T CB SV 10/15/100A W/BU AT&T SV 10/15/100A W/BU AT&T CB $3 23 SV 20-40/250D FEDS 06 $7 $5G/$10B FEDS 2003 I/P BH/MH 100% FEDS 2004 I/P MH/CD RESERVED FOR RX PPO RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX I/P CD 100% FEDS RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX SV 10/100% FORD HRLY 05 SV 10/100% FORD HRLY 05 CB SV 10/100% FORD HRLY 05 SV 10/100% FORD HRLY 05 CB SV 20/100% FORD SAL 05 SV 20/100% FORD SAL 05 CB SV 20/100% FORD SAL 05 SV 20/100% FORD SAL 05 CB SV 20-40/400D FEDS SV 20-40/400D FEDS FEDERAL EMPLOYEES PLAN FEDERAL EMPLOYEE PLAN 1992 ADMINISTRATIVE RETENTION SV 20-40/250D FEDS 06 FEDS DENTAL INDEMNITY 2001 SV 10/100% FORD HRLY 06 SV 10/100% FORD HRLY 06 CB SV 10/100% FORD HRLY 06 SV 10/100% FORD HRLY 06 CB SV 25/240A FIDELITY 07 $10G/RESCRIP DRUG $10 (FM) O/P PRESCRIP DRUGS $3 (MF) O/P PRESCRIP DRUGS $5 (MF) O/P PRESCRIP DRUGS $7 (MF) O/P PRESCRIP DRUGS $8 (MF) I/P MH 100% FEDS 314 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit FMM FMN FMZ FN1 FN2 FN3 FN4 FN5 FN6 FN7 FN8 FNA FNB FND FNE FNZ FQB FQF FR1 FR2 FR3 FR4 FR5 FRA FRC FRD FRE FRM FRS FRX FRZ FS1 FS2 FS3 FS4 FSA FSB FSC FSD FSL FTL FUB FV2 FV3 FV4 FV5 FWD FX3 FX5 FX7 Plan / Benefit Description SV $15-$30/$250A FARMER SV $15-$30/$250A FARMER SV $15-$30/$250A FARMER CB FNF $10 - $15 / $250 FNF $10 - $15 / $250 COBRA FNF $10 - $15 / $250 FNF $10 - $15 / $250 COBRA NORTHROP GRUMANN $10/$20 NORTHROP GRUMANN 10/20 CBR NORTHROP GRUMANN $10/$20 NORTHROP GRUMANN 10/20 CBR SV 10-15/250A W/BU FID SV 10-15/250A W/BU FID CB SV 10-15/250A W/BU FID SV 10-15/250A W/BU FID CB SV $15-$30/$250A FARMER CB SV 20-40/250D FEDS 08 SV 25/240A FIDELITY 07 CB FEDERAL RETIREES PLAN FARMERS $15-$30/$250 FARMERS $15-$30/$250 COBRA FARMERS $15-$30/$250 FARMERS $15-$30/$250 COBRA RISK CHARGE - AGGREGATE ROCKWELL INT. HOURLY FORD SALARIED $20/100% FORD SALARIED $20/100% ROCKWELL INT. HOURLY RISK CHARGE - SPECIFIC ROCKWELL INT. HOURLY-COBRA ROCKWELL INT HOURLY-COBRA HMO SMALL GRP $20/$400 CBR HMO SMALL GRP $20/$400 CBR OK SG HMO $20/$40/$250D CB OK SG HMO $20/$40/$250D CB HMO SMALL GROUP $20/$400 HMO SMALL GROUP $20/$400 OK SG HMO $20/$40/$250D OK SG HMO $20/$40/$250D SILVER SNEAKER SH/GR-WL07 SILVER SNEAKER SH/GR-WL08 SV 20-40/250D FEDS 08 FORD-VISTEON $10/100% FORD-VISTEON $10/100% CBRA FORD-VISTEON $10/100% FORD-VISTEON $10/100% CBRA SV 25/240A FIDELITY 07 O/P PRESCRIP DRUGS $3 (F) $5G FORMULARY O/P PRESCRI DRUGS $7 (F) 315 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit FX8 FYD FZD FZE GDC GDF GEC GEF GKB GKD GKE GKG GM1 GM2 GM3 GM4 GM5 GM6 GM7 GM8 GMC GME GMF GMG GMH GMJ GMK GMR GP2 GP3 GP4 GP5 GP6 GP7 GP8 GP9 GS1 GS2 GSA GSB H01 H02 H03 H04 H05 H06 H07 H08 H09 H10 Plan / Benefit Description $8G FORMULARY ) SV 25/240A FIDELITY 07 CB FORD SALARIED $20/100% CBR FORD SALARIED $20/100% CBR SV 10/100% GM 06 SV 10/100% GM 06 CB SV 10/100% GM 06 SV 10/100% GM 06 CB SV 20-40/250A 07 SV 20-40/250A 07 CB SV 20-40/250A 07 SV 20-40/250A 07 CB GM SAL 2003 $15/100% GM SAL 2003 $15/100% COBRA GM HRLY 2003 $10/100% GM HRLY 2003 $10/100% CBR GM SAL 2003 $15/100% GM SAL 2003 $15/100% COBRA GM HRLY 2003 $10/100% GM HRLY 2003 $10/100% CBR SV 20-30/100% 06 SV 20/100% GM SALARIED SV 20/100% GM SALARIED CB SV 20/100% GM SALARIED SV 20/100% GM SALARIED CB SV 20-30/100% 06 CB SV 20-30/100% 06 SV 20-30/100% 06 CB PBG 20-30/100D PBG 20-30/100D COBRA PBG 20-30/100D PBG 20-30/100D COBRA SV 20-30/100D W/BU PBG SV 20-30/100D W/BU PBG CB SV 20-30/100D W/BU PBG SV 20-30/100D W/BU PBG CB HMO SMALL GRP $25/$600 CBR HMO SMALL GRP $25/$600 CBR HMO SMALL GROUP $25/$600 HMO SMALL GROUP $25/$600 DOMESTIC PARTNERSHIP PPO VISION CARE BENEFIT PPO FAMILY PLANING BENEFIT PPO 24/HOUR HEALTH INFO PPO HEARING AID BENEFIT PPO MENTAL NON-SMI PPO 90/70 RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT MENTAL NON-SMI PPO 80/60 MENTAL NON-SMI PPO 80/50 316 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit H11 H12 H13 H14 H15 H16 H17 H18 H19 H1A H1C H1F H1H H1L H1M H1P H1R H1S H1T H1W H1X H1Y H1Z H20 H21 H22 H23 H24 H25 H26 H27 H28 H29 H30 H31 H32 H33 H34 H35 H36 H37 H38 H39 H40 H41 H42 H43 H44 H45 H46 Plan / Benefit Description MENTAL NONSMI INDEMNITY 80 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO HEARING AID BENEFIT BASIC PLAN CREATED IN ERROR BASIC PLAN COBRA BASIC PLAN BASIC PLAN BASIC PLAN (OPT) BASIC PLAN (OPT) BASIC PLAN (OPT) BASIC PLAN (OPT) COBRA BASIC PLAN (OPT) COBRA BASIC PLAN COBRA BASIC PLAN (OPT) BASIC PLAN COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 317 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit H47 H48 H49 H50 H51 H52 H53 H54 H55 H56 H57 H58 H59 H60 H61 H62 H63 H64 H65 H66 H67 H68 H69 H6P H70 H71 H72 H73 H74 H75 H76 H77 H78 H79 H80 H81 H82 H83 H84 H85 H86 H87 H88 H89 H8A H8B H8D H8J H90 H91 Plan / Benefit Description RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 15-25/100A GR06 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 0/500A 3YRS PL HA-SH08 0/1300A 3YRS DX HA-SH08 0/800A 3YRS DX HA-SH08 5/400A 3YRS HA-SH08 RESERVED FOR PPO RESERVED FOR PPO 318 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit H92 H93 H94 H95 H96 H97 H98 H99 HA0 HA5 HAA HAC HAJ HAN HB1 HB2 HB3 HDE HF6 HHE HL8 HOA HOE HOI HPE HQ6 HQ7 HQ9 HQD HQE HQN HQO HQP HR2 HR3 HRD HRE HRP HRY HTC HU6 HU7 HU9 HUD HUE HUN HUO HUP I01 I02 Plan / Benefit Description RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO HEARING AID BENEFIT HEARING AID ($500 MAX) HEARING AID BENEFIT-CUSTOM HEAR AID 1EA EAR EA36 13YR HEARING AID $500 EVERY 3YR 300A/24M GR-HA07 RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT 300A 2YRS HA-GR08 25/400A 3 YRS SH-HA06 500A 3YRS HA-GR08 400A 3YRS 0PREM HA-GR08 RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED PFFS MCC OKCTY PP-PL SH07 MCC OKCTY EP-PL SH07 MCC OKCTY PLUS SH07 MCC OKCTY DELUXE SH07 MCC OKCTY EP SH07 MC COMP OKCTY SH07 MCC OKCTY PL-DLXE SH07 MCC OKCTY PP SH07 HRING AID $500 ALLOWANCE HRING AID $300 ALLOWANCE 0/800A 3YRS DX SH-HA07 5/400A 3YRS SH-HA07 0/500A 3YRS PL SH-HA07 0/1300A 3YRS DX SH-HA07 500A 2YRS HA-GR08 MCC ESS OKCTY PP-PL SH07 MCC ESS OKCTY EP-PL SH07 MCC ESS OKCTY PLUS SH07 MCC ESS OKCTY DELUXE SH07 MCC ESS OKCTY EP SH07 MC COMP ESS OKCTY SH07 MCC ESS OKCTY PL-DLXE SH07 MCC ESS OKCTY PP SH07 INDEMNITY COVERAGE PLAN INDEMNITY COVERAGE PLAN 319 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit I03 I0K I0L I0T I11 I12 I13 I16 I17 I1A I1B I1C I1J I1K I1P I1Z I21 I22 I23 I26 I27 I2A I2B I2C I2J I2K I2P I2Z I31 I32 I33 I36 I37 I3A I3B I3C I3J I3K I3P I3Z I41 I42 I43 I46 I47 I4A I4B I4C I4J I4K Plan / Benefit Description INDEMNITY PLAN INDEMNITY OKLAHOMA CITY 23DEMNITY SOUTHWEST INDEMNITY TULSA LARGE GRP PPO PLAN 1 CBRA LARGE GRP PPO PLAN 1 CBRA LARGE GRP PPO PLAN 1 CBRA PPO PLAN1 LG/CBR-PHCS NTWK PPO PLAN1 LG/CBRA-PHCS NET LARGE GROUP PPO PLAN 1 LARGE GROUP PPO PLAN 1 LARGE GROUP PPO PLAN 1 PPO PLAN 1 LG-PHCS NETWORK PPO PLAN 1 LG-PHCS NETWORK NATIONAL PPO TULSA NATIONAL PPO/COBRA TULSA LARGE GRP PPO PLAN 2 CBRA LARGE GRP PPO PLAN 2 CBRA LARGE GRP PPO PLAN 2 CBRA PPO PLAN2 LG/CBRA-PHCS NET PPO PLAN2 LG/CBRA-PHCS NET LARGE GRP PPO PLAN 2 LARGE GRP PPO PLAN 2 LARGE GRP PPO PLAN 2 PPO PLAN 2 LG-PHCS NETWORK PPO PLAN 2 LG-PHCS NETWORK NATIONAL PPO OKLAHOMA CITY NATIONAL PPO/COBRA OK CITY LARGE GRP PPO PLAN 3 CBRA LARGE GRP PPO PLAN 3 CBRA LARGE GRP PPO PLAN 3 CBRA PPO PLAN3 LG/CBRA-PHCS NET PPO PLAN3 LG/CBRA-PHCS NET LARGE GROUP PPO PLAN 3 LARGE GROUP PPO PLAN 3 LARGE GROUP PPO PLAN 3 PPO PLAN 3 LG-PHCS NETWORK PPO PLAN 3 LG-PHCS NETWORK NATIONAL PPO LAWTON NATIONAL PPO/COBRA LAWTON LARGE GRP PPO PLAN 4 CBRA LARGE GRP PPO PLAN 4 CBRA LARGE GRP PPO PLAN 4 CBRA PPO PLAN4 LG/CBRA-PHCS NET PPO PLAN4 LG/CBRA-PHCS NET LARGE GROUP PPO PLAN 4 LARGE GROUP PPO PLAN 4 LARGE GROUP PPO PLAN 4 PPO PLAN 4 LG-PHCS NETWORK PPO PLAN 4 LG-PHCS NETWORK 320 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit I51 I52 I53 I56 I57 I5A I5B I5C I5J I5K I5P I5X I61 I62 I63 I6A I6B I6C I6P I6X I71 I72 I73 I7A I7B I7C I81 IA0 IA1 IA2 IA3 IA4 IA5 IA6 IA7 IA8 IA9 IB0 IB1 IB2 IB3 IB4 IB5 IB6 IB7 IB8 IB9 IBZ IC1 IC2 Plan / Benefit Description LARGE GRP PPO PLAN 5 CBRA LARGE GRP PPO PLAN 5 CBRA LARGE GRP PPO PLAN 5 CBRA PPO PLAN5 LG/CBRA-PHCS NET PPO PLAN5 LG/CBRA-PHCS NET LARGE GROUP PPO PLAN 5 LARGE GROUP PPO PLAN 5 LARGE GROUP PPO PLAN 5 PPO PLAN 5 LG-PHCS NETWORK PPO PLAN 5 LG-PHCS NETWORK NATIONAL PPO- PHCS NETWORK NATIONAL PPO-PHCS NTWK COB LARGE GRP IND PLAN 6 CBRA LARGE GRP IND PLAN 6 CBRA LARGE GRP IND PLAN 6 CBRA LARGE GRP INDEMNITY PLAN 6 LARGE GRP INDEMNITY PLAN 6 LARGE GRP INDEMNITY PLAN 6 NATIONAL PPO- PHCS NETWORK NATIONAL PPO-PHCS NTWK COB LARGE GRP IND PLAN 7 CBRA LARGE GRP IND PLAN 7 CBRA LARGE GRP IND PLAN 7 CBRA LARGE GRP INDEMNITY PLAN 7 LARGE GRP INDEMNITY PLAN 7 LARGE GRP INDEMNITY PLAN 7 IND.CONV.PLAN-880 PPO PLAN10 15 80/60 250 PPO PLAN1 15 90/70 250 PPO PLAN2 20 90/70 250 PPO PLAN3 10 90/70 250 PPO PLAN4 20 90/70 500 PPO PLAN5 15 80/60 500 PPO PLAN6 20 90/70 500 PPO PLAN7 10 80/60 500 PPO PLAN8 20 80/60 500 PPO PLAN9 25 80/60 500 PPO PLAN10 15 80/60 250 PPO PLAN1 15 90/70 250 PPO PLAN2 20 90/70 250 PPO PLAN3 10 90/70 250 PPO PLAN4 20 90/70 500 PPO PLAN5 15 80/60 500 PPO PLAN6 20 90/70 500 PPO PLAN7 10 80/60 500 PPO PLAN8 20 80/60 500 PPO PLAN9 25 80/60 500 RESERVED INDEMNITY PPO - COBRA INDEMNITY PPO - COBRA 321 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit IC3 IC4 IC5 IC6 IC7 ICA ICB ICC ICD IE1 IG1 IG2 IG3 IJ1 IK1 IK2 IK3 IK4 IN1 IN2 IN3 IN4 IP1 IP2 IP3 IQ1 IQ2 IQ3 IS1 IS2 IS3 IS4 IX1 IX2 IX3 IX4 IZ1 IZ2 IZ3 IZK IZL IZT J1C J1D J1F J1G J1H J1I J1J J1K Plan / Benefit Description INDEMNITY PPO - COBRA PPO CUSTOM COBRA PPO CUSTOM COBRA PPO CUSTOM COBRA-PHCS NTWK PPO CUSTOM COBRA-PHCS-NTWK PPO CUSTOM PPO CUSTOM PPO CUSTOM - PHCS NETWORK PPO CUSTOM - PHCS NETWORK PPO PLAN11 20 80/60 250 INDEMNITY PLAN - GI INDMENITY PLAN - GI INDEMNITY PLAN - GI PPO PLAN11 20 80/60 250 INDEMNITY CUSTOM INDEMNITY CUSTOM COBRA INDEMNITY CUSTOM INDEMNITY CUSTOM COBRA INDEMNITY PLAN1 80% 250 INDEMNITY PLAN2 80% 500 INDEMNITY PLAN1 80% 250 INDEMNITY PLAN2 80% 500 INDEMNITY PPO INDEMNITY PPO INDEMNITY PPO INDEMNITY PLAN - GI INDEMNITY PLAN - GI INDEMNITY PLAN REGIONAL LG $20/80% REGIONAL LG $20/80% COBRA REGIONAL LG $20/80% REGIONAL LG $20/80% COBRA INDEMNITY PLAN1 80% 250 CB INDEMNITY PLAN2 80% 500 CB INDEMNITY PLAN1 80% 250 CB INDEMNITY PLAN2 80% 500 CB INDEMNITY PLAN COBRA INDEMNITY PLAN COBRA INDEMNITY PLAN INDEMNITY-OK CITY COBRA INDEMNITY-SOUTHWEST COBRA INDEMNITY COBRA 880 PLAN PLAN ONE PLAN ONE 23200 880 PLAN COBRA 880 PLAN - IND. CONVR. 880 PLAN - INDVDL CNVRSN KP200 322 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit J1L J1M J1N J1P J1Q J1R J1S J1T J1U J1V J1W J1X J1Y J1Z JMD JMF JMQ JMZ JNZ JPM JPN JR1 JR2 K6E K6M KA2 KA3 KA4 KA5 KA6 KA7 KA8 KA9 KB2 KB3 KB4 KB5 KB6 KB7 KB8 KB9 KC6 KCE KCN KD2 KD3 KD4 KD5 KD6 KD7 Plan / Benefit Description 880 PLAN 880 PLAN 880 PLAN - IND. CONVRN. 880 PLAN (OPT) PLAN ONE 880 PLAN (OPT) 880 PLAN (OPT) 880 PLAN (OPT) COBRA KP200 KP200 880 PLAN (OPT) COBRA 880 PLAN COBRA 880 PLAN (OPT) COBRA 880 PLAN COBRA PLAN ONE PLAN ONE PLAN ONE SV 20-30/250A JPMORGAN CB SV 20-30/250A JPMORGAN CB SV 20-30/250A JPMORGAN SV 20-30/250A JPMORGAN JCPENNY GRP RET $5/100% JC PENNY GRP RET $5/100% 5/10 OKCITY CE SH06 D466 5/10 OKCITY M SH06 D466 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO ESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 5/25 OKCITY C SH06 D466 5/25 OKCITY C SH06 EPO 5/25 OKCITY C SH06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 323 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit KD8 KD9 KE2 KE3 KE4 KE5 KE6 KE7 KE8 KE9 KEE KEN KF2 KF3 KF4 KF5 KF6 KF7 KF8 KF9 KG2 KG3 KG4 KG5 KG6 KG7 KG8 KG9 KH1 KH2 KH3 KH4 KH5 KH6 KH7 KH8 KH9 KJ2 KJ3 KJ4 KJ5 KJ6 KJ7 KJ8 KJ9 KJI KJO KJQ KJU KJV Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 5/10 OKCITY CE SH06 EPO 5/10 OKCITY CE SH06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO HEALTH EVALUATION RIDER HEALTH EVALUATION RIDER HEALTH EVALUATION RIDER HEALTH EVALUATION RIDER HEALTH EVALUATION RIDER HEALTH EVALUATION RIDER HEALTH EVALUATION RIDER RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO ARP MCC OKCTY EP-PL SH08 ARP MCC OKCTY PL-DLX SH08 ARP MCC OKCTY PP-PL SH08 ARP MCC OKCTY PP SH08 ARP MCC OKCTY PLUS SH08 324 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit KJW KJX KJY KL2 KL3 KL4 KL5 KL6 KL7 KL8 KL9 KM2 KM3 KM4 KM5 KM6 KM7 KM8 KM9 KME KMN KR2 KR3 KR4 KR5 KR6 KR7 KR8 KR9 KS2 KS3 KS4 KS5 KS6 KS7 KS8 KS9 KT2 KT3 KT4 KT5 KT6 KT7 KT8 KT9 KU2 KU3 KU4 KU5 KU6 Plan / Benefit Description ARP MCC OKCTY SH08 ARP MCC OKCTY DLX SH08 ARP MCC OKCTY EP SH08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 5/10 OKCITY M SH06 EPO 5/10 OKCITY M SH06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 325 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit KU7 KU8 KU9 KV2 KV3 KV4 KV5 KV6 KV7 KV8 KV9 KW2 KW3 KW4 KW5 KW6 KW7 KW8 KW9 KX2 KX3 KX4 KX5 KX6 KX7 KX8 KX9 KY2 KY3 KY4 KY5 KY6 KY7 KY8 KY9 L10 L11 L12 L13 L14 L15 L16 L17 L18 L19 L20 L21 L22 L23 L24 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO LIFE W/O SEAT LRG TULSA LIFE W/O SEAT LRG TULSA LIFE W/O SEAT LRG TULSA LIFE W/O SEAT LRG TULSA LIFE W/SEAT LRG TULSA LIFE W/SEAT LRG TULSA LIFE W/SEAT LRG TULSA LIFE W/SEAT LRG TULSA LIFE W/O SEAT SMALL TULSA LIFE W/SEAT SMALL TULSA LIFE W/O SEAT LRG OK CITY LIFE W/O SEAT LRG OK CITY LIFE W/O SEAT LRG OK CITY LIFE W/O SEAT LRG OK CITY LIFE W/SEAT LRG OK CITY 326 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit L25 L26 L27 L28 L29 L30 L31 L32 L33 L34 L35 L36 L37 L38 L39 L49 L50 L51 L52 L53 L54 L55 L56 L57 L58 L59 L60 L61 L62 LD1 LD2 LDA LDB LF1 LF2 LF3 LH2 LH3 LH4 LH5 LL3 LM1 LO1 LO2 LO3 LO4 LO5 LTD LTM M03 Plan / Benefit Description LIFE W/SEAT LRG OK CITY LIFE W/SEAT LRG OK CITY LIFE W/SEAT LRG OK CITY LIFE W/O SEAT SMALL OK CIT LIFE W/SEAT SMALL OK CITY LIFE W/O SEAT LRG LAWTON LIFE W/O SEAT LRG LAWTON LIFE W/SEAT LRG LAWTON LIFE W/SEAT LRG LAWTON LIFE W/SEAT LRG LAWTON LIFE W/SEAT LRG LAWTON LIFE W/SEAT LRG LAWTON LIFE W/SEAT LRG LAWTON LIFE W/O SEAT SMALL LAWTON LIFE W/SEAT SMALL LAWTON LIFE SMALL GROUP - TULSA LIFE SMALL GROUP - TULSA LIFE SM GRP INTERNET TULSA LIFE SM GRP INTERNET TULSA LIFE MID/LG GROUP - TULSA LIFE MID/LG GROUP - TULSA LIFE MID/LG GROUP - TULSA LIFE SMALL GROUP - OK CITY LIFE SMALL GROUP - OK CITY LIFE SMALL INTERNET OK CIT LIFE SMALL INTERNET OK CIT LIFE MID/LG GROUP- OK CITY LIFE MID/LG GROUP- OK CITY LIFE MID/LG GROUP- OK CITY SV 7-ELEVEN 20-30/500A CB SV 7-ELEVEN 20-30/500A CB SV 7-ELEVEN 20-30/500A SV 7-ELEVEN 20-30/500A LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN LOCKHEED $20/100% LOCKHEED $20/100% COBRA LOCKHEED $20/100% LOCKHEED $20/100% COBRA LIFELINK ALREADY USED OK PLAN I LIMITED FEE OK PLAN II LIMITED FEE OK PLAN III LIMITED FEE OK PLAN IV LIMITED FEE OK PLAN V LIMITED FEE RESERVED FOR PPO LIFE RESERVED FOR LIFETIME MAX MEDICAID 327 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit M15 M1C M1H M1L M1M M1P M1R M1S M1T M1W M1X M1Y M1Z MD1 MH1 MH2 MH3 MH5 MH8 MK1 MK2 MK5 MK6 MKZ MMC MMH MML MMM MMX MMZ MR1 MR2 MR3 MR4 MSC MSH MSL MSM MSX MSZ MTK MTM MZ1 MZK N02 N04 N05 N06 N07 N08 Plan / Benefit Description $15 2070 PLAN 2070 PLAN COBRA 2070 PLAN 2070 PLAN 2070 PLAN (OPT) 2070 PLAN (OPT) 2070 PLAN (OPT) 2070 PLAN (OPT) COBRA 2070 PLAN (OPT) COBRA 2070 PLAN COBRA 2070 PLAN (OPT) COBRA 2070 PLAN COBRA MC DONNELL DOUGLAS PLAN MENTAL HEALTH O/P $5 OV MENTAL HEALTH O/P $10 OV MENTAL HEALTH O/P $15 OV MENTAL HEALTH - $500/DAY MENTAL HEALTH - 80% MCKESSON RET $0/100% MCKESSON RET $0/100% SV 20-30/90% MCKESSON SV 20-30/90% MCKESSON SV 20-30/90% MCKESSON CB 2070 UNINSURED WORKERS 2070 UNINSURED WRKRS COBRA 2070 UNINSURED WORKERS 2070 UNINSURED WORKERS 2070 UNINSURED WRKRS COBRA 2070 UNINSURED WRKS COBRA MARRIOTT $15-$25/$100 MARRIOTT $15-$25/$100 CBRA MARRIOTT $15-$25/$100 MARRIOTT $15-$25/$100 CBRA STATE CERTIFIED PLAN STATE CERTIFIED PLAN STATE CERTIFIED PLAN STATE CERTIFIED PLAN STATE CERTIFIED PLAN STATE CERTIFIED PLAN 10/5V 1YR MSG THRPY SH07 10/5V 1YR MSG THRPY SH08 MC DONNELL DOUGLAS (COBRA) SV 20-30/90% MCKESSON CB INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS 328 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit N09 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N1C N1G N1H N1K N1L N1M N1P N1R N1S N1T N1U N1V N1W N1X N1Y N1Z N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N8F NA1 NA2 NA3 NA4 NA5 NA6 NA7 NA8 NAA NAB NAC Plan / Benefit Description INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS SHARE PLAN KP300 SHARE PLAN COBRA KP300 SHARE PLAN SHARE PLAN SHARE PLAN (OPT) SHARE PLAN (OPT) SHARE PLAN (OPT) SHARE PLAN (OPT) COBRA KP300 KP300 SHARE PLAN (OPT) COBRA SHARE PLAN COBRA SHARE PLAN (OPT) COBRA SHARE PLAN COBRA INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS SV $20-$40/$400D CB PHS NATL $5/100% COBRA PHS NATL $10/100% COBRA PHS NATL $10/$100/100% CBR PHS NATL $10/$250/100%CBRA PHS NATL $15/$250/100%CBRA PHS NATL $15/100% COBRA NATIONAL $15/$100 COBRA NATIONAL $20/$250 COBRA PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100/100% 329 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit NAD NAE NAF NAG NAH NAK NAL NAM NAN NAO NAP NAQ NAR NAX NB1 NB2 NB3 NB4 NC1 NC2 NC3 NCA NCB NCC NF0 NF4 NF5 NF6 NF7 NF8 NF9 NFD NFE NFF NFG NFH NFI NFJ NFK NFL NFM NFY NGA NGB NGC NGD NGZ NHZ NJ1 NJ2 Plan / Benefit Description PHS NATL $10/$250/100% PHS NATL $15/$250/100% PHS NATL $15/100% NATL POS $10/100%/70% NATL POS $10/90%/70% NATL POS $15/80%/60% NATL POS $15/$150/70% NATIONAL $15/$100 NATL POS $10/100%/70% NATL POS $10/90%/70% NATIONAL $20/$250 NATL POS $15/80%/60% NATL POS $15/$150/70% DUMMY OK TO USE BOEING IAM $10/100% BOEING IAM $10/100% COBRA BOEING IAM $10/100% BOEING IAM $10/100% COBRA $10/100% MERCER PLAN 1 CBR $15/100% MERCER PLAN 2CBRA $15/$500 MERCER PLAN 3CBRA $10/100% MERCER PLAN 1 $15/100% MERCER PLAN 2 $15/$500 MERCER PLAN 3 SV 15-30/250A NAT'L CB SV 10-20/100A CB SV 15-30/250A NAT'L CB SV $15-$30/$400A CB SV $20-$40/$250D CB SV $20-$40/$400D CB SV 10-20/100A CB SV 10-20/100A SV 15-30/250A NAT'L SV $15-$30/$400A SV $20-$40/$250D SV $20-$40/$400D SV 10-20/100A SV 15-30/250A NAT'L SV $15-$30/$400A SV $20-$40/$250D SV $20-$40/$400D SV $15-$30/$400A CB NAT'L PLN 2C $20 GRP RET NAT'L PLN 2C $20 GRP RET NAT'L PLN 2D $20 GRP RET NAT'L PLN 2D $20 GRP RET NATL POS $10/100%/70% CBRA NATL POS $10/90%/70% COBRA SV $5/100% NATL CB SV $10/100% NATL CB 330 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit NJ3 NJ4 NJ5 NJ6 NJ7 NJA NJB NJC NJD NJE NJF NJG NK1 NK2 NK3 NK4 NK5 NK6 NK7 NKZ NL8 NLF NLG NLZ NMC NMH NML NMM NMX NMZ NN1 NN2 NN3 NN4 NN5 NN6 NN7 NNA NNB NNC NND NNE NNF NNG NNZ NO1 NO2 NO3 NO4 NOZ Plan / Benefit Description SV $15/100% CB SV $10/$100A NATL CB SV $10/$250A NATL CB SV $15/$250A CB SV $15/$100A CB SV $5/100% NATL SV $10/100% NATL SV $15/100% SV $10/$100A NATL SV $10/$250A NATL SV $15/$250A SV $15/$100A NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 2B $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET NATL POS $15/80%/60% COBRA 24HR NURSLINE WL-SH/GR08 SV $20-$40/$250D CB 24HOUR NURSE LINE SH07 NATL POS $15/$150/70% CBRA SHARE PLAN SHARE PLAN COBRA SHARE PLAN SHARE PLAN SHARE PLAN COBRA SHARE PLAN COBRA SV $5/100% NATL CB SV $10/100% NATL CB SV $15/100% CB SV $10/$100A NATL CB SV $10/$250A NATL CB SV $15/$250A CB SV $15/$100A CB SV $5/100% NATL SV $10/100% NATL SV $15/100% SV $10/$100A NATL SV $10/$250A NATL SV $15/$250A SV $15/$100A NATL POS $10/100%/70% CBRA ORU $15/$250/100% ORU $15/$250/100% COBRA ORU $15/$250/100% ORU $15/$250/100% COBRA NATL POS $10/90%/70% COBRA 331 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit NQZ NR0 NR1 NR2 NR3 NR4 NR5 NR6 NR7 NR8 NR9 NRA NRB NRC NRD NRE NRF NRG NRH NRI NRJ NRZ NS1 NS2 NSC NSF NSH NSL NSM NSX NSZ NT1 NT2 NT3 NT4 NT5 NT6 NT7 NTB NTL NTU NV1 NV2 NV3 NVA NVB NVC NW1 NW2 NW3 Plan / Benefit Description NATL POS $15/80%/60% COBRA NAT'L $20/$40/$400 DAY CBR NAT'L $10/$20/$100 COBRA NAT'L $15/$30/$250 COBRA NAT'L $15/$30/$400 COBRA NAT'L $20/$40/$250 DAY CBR NAT'L $20/$40/$400 DAY CBR NAT'L $10/$20/$100 COBRA NAT'L $15/$30/$250 COBRA NAT'L $15/$30/$400 COBRA NAT'L $20/$40/$250 DAY CBR NAT'L $10/$20/$100 NAT'L $15/$30/$250 NAT'L $15/$30/$400 NAT'L $20/$40/$250 PER DAY NAT'L $20/$40/$400 PER DAY NAT'L $10/$20/$100 NAT'L $15/$30/$250 NAT'L $15/$30/$400 NAT'L $20/$40/$250 PER DAY NAT'L $20/$40/$400 PER DAY NATL POS $15/$150/70% CBRA NEW SHARE PLAN NEW SHARE PLAN STATE OF OKLA. LOW OPTION OPT SHARE PLAN STATE OF OKLAHOMA STATE OF OKLAHOMA STATE OF OKLAH. LOW STATE OF OKLAH. LOW COBRA STATE OF OKLAH. LOW COBRA NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 2B $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET 0/24-1W NON-ER TRANS SH07 0/24-1W NON-ER TRANS SH08 0/20-1W NON-ER TRANS SH08 $10/100% MERCER PLAN 1CBRA $15/100% MERCER PLAN2 COBR $15/$500 MERCER PLAN 3 CBR $10/100% MERCER PLAN 1 $15/100% MERCER PLAN 2 $15/$500 MERCER PLAN 3 $10/100% MERCER PLAN 1 CBR $15/100% MERCER PLAN 2CBRA $15/$500 MERCER PLAN 3CBRA 332 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit NWA NWB NWC NX1 NX2 NX3 NX4 NX5 NX6 NXA NXB NXC NXD NXE NXF NY1 NY2 NY3 NY4 NY5 NY6 NY7 NY8 NYA NYB NYC NYD NYE NYF NYM NYP O12 O14 O1C O1K O1Q O1R O1T O1U O1V O1W O1X O22 O27 O2A O2C O2D O2G O2H O2K Plan / Benefit Description $10/100% MERCER PLAN 1 $15/100% MERCER PLAN 2 $15/$500 MERCER PLAN 3 PHS NATL $5/100% COBRA PHS NATL $10/100% PHS NATL $10/$100/100%CBRA PHS NATL $10/$250/100%CBRA PHS NATL $15/$250/100%CBRA PHS NATL $15/100% COBRA PHS NATL $5/100% PHS NATL $10/100% CHS NATL $10/$100/100% PHS NATL $10/$250/100% PHS NATL $15/$250/100% PHS NATL $15/100% PHS NATL $5/100% COBRA PHS NATL $10/100% COBRA PHS NATL $10/$100/100%CBRA PHS NATL $10/$250/100%CBRA PHS NATL $15/$250/100%CBRA PHS NATL $15/100% COBRA NATIONAL $15/$100 COBRA NATIONAL $20/$250 COBRA PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100/100% PHS NATL $10/$250/100% PHS NATL $15/$250/100% PHS NATL $15/100% NATIONAL $15/$100 NATIONAL $20/$250 NAT'L PLN 1 $5 GR 06 NAT'L PLN 1 $5 GR 06 SH-MCDONNELL DOUGLAS - C NAT'L PLN 1 $5 GRP RET 10-20/750A T2A GR07 15-25/200D T3A GR07 NAT'L PLN 1 $5 GRP RET 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 NAT'L PLN 2 $10 GRP RET 2070 PLAN SV 10/100% SH-MCDONNELL DOUGLAS - C SV 20/100% 05 SV 20/400A 05 BOEING NA-HRLY $10 GRP RET NAT'L PLN 2 $10 GRP RET 333 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit O2N O2Q O2R O2T O2U O2V O2W O2X O3A O3D O3G O3H O3Q O3R O3U O3V O3W O3X O41 O42 O44 O4H O4K O4Q O4R O4U O4V O4W O4X O52 O5H O5M O5P O5Q O5R O5U O5V O5W O5X O61 O62 O64 O6Q O6R O6U O6V O6W O6X O71 O72 Plan / Benefit Description NAT'L PLN 2 $10 GRP RET 10-20/750A T2A GR07 15-25/200D T3A GR07 NAT'L PLN 2 $10 GRP RET 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 SV 10/100% CB SV 20/100% 05 CB SV 20/400A 05 CB BOEING NA-HRLY $10 GRP RET 10-20/750A T2A GR07 15-25/200D T3A GR07 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 BOEING HOURLY $15 GRP RET NAT'L PLN 2A $10 GRP RET 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 5100 PLAN BOEING HOURLY $15 GRP RET 15 BO SCPEA NO-AARP GR08 15 BO SCPEA NO-AARP GR08 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 334 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit O74 O7H O7Q O7R O7T O7U O7V O7W O7X O82 O88 O8B O8F O8Q O8R O8U O8V O8W O8X O91 O92 O94 O9Q O9R O9U O9V O9W O9X OA2 OA3 OA5 OA6 OA7 OA8 OAN OB2 OBA OBR OBZ OC1 OC2 OCA OCB OCC OCN OCR OCZ OD2 OD3 ODN Plan / Benefit Description NAT'L PLN 3B $15 GR 06 $15/$200 BOEING GR 10-25/150D T2C GR07 20-35/250D T3C GR07 NAT'L PLN 3B $15 GRP RET 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 880 PLAN 880 PLAN $15/$200 BOEING GR 880 PLAN OPT 10-25/150D T2C GR07 20-35/250D T3C GR07 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 10-25/150D T2C GR07 20-35/250D T3C GR07 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 SV 10/100% SV 10/100% CB STATE OF OK ALT OPTION STATE OF OK ALT OPTION CBR STATE OF OK ALT OPTION STATE OF OK ALT OPTION CBR NATIONAL ACCT EXTENDED OOA BASIC PLAN BASIC PLAN 5/100% AARP GR08 15/250A NON-AARP GR08 OKLAHOMA CITY PLAN 1 OKLAHOMA CITY PLAN 2 OK SH STANDARD PLAN OK SH STANDARD PLAN 05 OK SH STANDARD PLAN W/D SV 20-40/250D OC PET 07 5/100% AARP GR08 15/250A NON-AARP GR08 SV 20/100% 05 SV 20/100% 05 CB SV 20-40/250D OC PET 07 335 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit ODT OE1 OE2 OE4 OEN OEQ OET OF1 OF2 OF3 OF4 OF5 OF6 OF7 OF8 OF9 OFA OFB OFC OFD OFE OFQ OG2 OG3 OGA OGB OGJ OGL OGR OH1 OH2 OH3 OH4 OH5 OH6 OH7 OH8 OHR OI1 OI2 OI4 OI8 OJ1 OJ2 OJ4 OJN OK1 OK2 OK3 OK4 Plan / Benefit Description 10/100% AARP GR08 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 SV 20-40/250D OC PET 07 CB 20/100% NON-AARP GR08 10/100% AARP GR08 RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO 20/100% NON-AARP GR08 SV 20/400A 05 SV 20/400A 05 CB NAT'L PLN 2C $20 GRP RET NAT'L PLN 2C $20 GRP RET 20/100% NON-AARP GR08 20/100% NON-AARP GR08 5/100% NON-AARP GR08 STATE OF OK HI OPTION STATE OF OK HI OPTION CBRA STATE OF OK HI OPTION STATE OF OK HI OPTION CBRA STATE OF OK HI OPTION STATE OF OK HI OPTION CBR STATE OF OK HI OPTION STATE OF OK HI OPTION CBR 5/100% NON-AARP GR08 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 IND.CONV.PLAN-880 NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 SV 20-40/250D OC PET 07 CB OKLAHOMA CTY STANDARD PLAN OKLAHOMA CTY PRT B ONLY OKLHMA CTY AREA-SH INDIV. OKLHMA CTY-AREA SH PRT B 336 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit OK6 OK7 OKG OKK OKL OKN OKP OKT OL1 OL2 OL3 OL4 OL5 OL6 OL7 OL8 OLT OM1 OM2 OMD ON1 ON2 ON3 ON4 ON5 ON6 ON7 ON8 ONF ONK ONS OO2 OO4 OO8 OON OP0 OP2 OP8 OPL OPR OPS OQ2 OQ4 OR1 OR2 OR4 OR5 ORX OS2 OS3 Plan / Benefit Description NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET 15 BO HRLY-F NO-AARP GR08 NAT'L PLN 2 $10 GRP RET 10 BO HRLY NO-AARP GR08 NAT'L PLN 1 $5 GRP RET 15 BO HRLY-F NO-AARP GR08 10/100% NON-AARP GR08 STATE OF OK LOW OPTION STATE OF OK LOW OPTION CBR STATE OF OK LOW OPTION STATE OF OK LOW OPTION CBR STATE OF OK LOW OPTION STATE OF OK LOW OPTION CBR STATE OF OK LOW OPTION STATE OF OK LOW OPTION CBR 10/100% NON-AARP GR08 MCDONNELL DOUG PLAN OKCITY $10G/$20B/$30NF NEW SHARE PLAN $10G/$25B/$50NF $15G/$25B/$40NF $15G/$25B $15G/$35B $10G/$25B/$40NF $10G/$35B SHARE PLAN (OPT) NAT'L PLN 2 $10 GRP RET NEW SHARE PLAN NAT'L PLN 1 $5 GR 06 NAT'L PLN 1 $5 GR 06 NOT USED POS - OUT OF AREA I/P PSYCH (45 DAY-100%) PREFERED PLAN I/P PSYCH (45 DAY-80%) 10 BO HRLY NO-AARP GR08 PREFERRED PLAN I/P PSYCH (STATE OF OKLA) NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 SH GRP RET $5/100% 2001 OTHR RX NOT THRU RX SOL STANDARD PLAN STATE OF OKLA. 1992 337 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit OS5 OST OSZ OT1 OT2 OT4 OT6 OTA OTB OTC OTG OTJ OTL OTT OU1 OU2 OU3 OU4 OU5 OU6 OUG OV1 OV2 OV4 OW1 OW2 OW4 OX2 OX4 OXW OYW OYZ OZ0 OZ1 OZ2 OZ3 OZ5 OZ7 OZ8 OZA OZB OZD OZF OZN OZP OZR OZS OZT OZZ P00 Plan / Benefit Description 5100 PLAN STANDARD PLAN STANDARD PLAN NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 3A $15 GRP RET OK SH STANDARD PLAN OK SH STANDARD PLAN 05 OK SH STANDARD PLAN W/D 15-25/500A AARP GR08 15/250A AARP GR08 15/250A AARP GR08 NAT'L PLN 2 $10 GRP RET OKLAHOMA SM GRP PLAN I UC OKLAHOMA SM GRP PLAN II UC OKLAHOMA SM GRP PLN III UC OKLAHOMA SM GRP PLAN IV UC OKLAHOMA SM GRP PLAN V UC OKLAHOMA SM GRP INDEM UC 15-25/500A AARP GR08 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 10-20/250A NON-AARP GR08 10-20/250A NON-AARP GR08 10/100% NON-AARP GR08 880 PLAN (COBRA) OKLAHOMA CITY PLAN 1 COBRA OKLAHOMA CITY PLAN 2 COBRA STATE OF OKLA. 1992 5100 PLAN COBRA 2070 PLAN 880 PLAN (COBRA) BASIC PLAN (COBRA) BASIC PLAN (COBRA) MCDON. DOUG OKCITY COBRA SHARE PLAN (COBRA-OPT) NEW SHARE PLAN (COBRA) PREFERRED PLAN (COBRA) PREFERRED PLAN NEW SHARE PLAN (COBRA) STANDARD PLAN (COBRA) 10/100% NON-AARP GR08 INPATIENT PSYCHIATRIC 100% 338 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit P0C P1C P2A P2C P2P P3P P45 P4P P5C P5P P6C P6H P6P P7C P7P P80 P8C P8P P9C P9P PA2 PA3 PA4 PA5 PA6 PA7 PA8 PA9 PAA PAB PAC PAD PAE PAF PAG PAH PAK PB1 PB2 PB3 PB4 PBA PBB PBF PBG PCD PCE PCH PCI PCW Plan / Benefit Description INPATIENT PSYCH 100% INPATIENT PSYCH $100 MENTAL HEALTH (AAON) INPATIENT PSYCH 80% RESERVED PPO RESERVED PPO I/P PSYCHIATRIC (45 DAY) RESERVED PPO INPATIENT PSYCH 50% RESERVED PPO INPATIENT PSYCH/MH 15-25/100A GR06 RESERVED PPO IP MH/PSYCH 100% 30D MERCE RESERVED PPO INPATIENT PSTCHIATRIC 80% IP MH/PSYCH $500 COPAY 30D RESERVED PPO IP MH 30 DAYS 100% FEDS RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PPO-PFFS RESERVED PFFS PPO ADMINISTRATIVE CHARGE RESERVED PFFS PPO - PFFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS PPO CUSTOM PPO CUSTOM COBRA PPO CUSTOM PPO CUSTOM COBRA PPO - PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS PBHI CHEMICAL DEP.-CUSTOM PPO - PFFS SV $15-$30/$100A PHS SV $15-$30/$100A PHS $45/Q PHB CREDIT SH08 339 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit PD1 PD2 PD3 PD4 PD5 PD6 PD7 PDH PDS PDW PEH PEK PEY PF2 PF3 PF4 PF5 PF6 PF7 PF8 PF9 PFA PFB PFC PFD PG1 PG2 PG3 PG4 PGD PH2 PH3 PH4 PH5 PH6 PH7 PH8 PH9 PHE PHF PHG PHH PHV PIE PIF PIG PIH PII PIK PIL Plan / Benefit Description $10G/$25B $1000 CMBNED MAX PDV CUSTOM DENTAL ONLY PDV VISION ONLY PDV CUSTOM VISION ONLY PDV DENTAL & VISION PDV CUSTOM DENTAL & VISION PDV DENTAL ONLY O/4V 1YR POD SH07 O/3V 1YR POD SH08 O/6V 1YR POD SH08 RESERVED PFFS RESERVED PFFS $20/Q PHB CREDIT SH08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20-40/200A PHS 06 SV 20-40/200A PHS 06 CB SV 20-40/200A PHS 06 SV 20-40/200A PHS 06 CB PBG $20/$200 PBG $20/$200 COBRA PBG $20/$200 PBG $20/$200 COBRA RESERVED PFFS RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20-30/100D 06 SV 20-30/100D 06 CB SV 20-30/100D 06 SV 20-30/100D 06 CB $45/Q PHB CREDIT SH07 RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS 340 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit PIN PIO PKC PKH PKL PKM PKX PKZ PLC PLD PLE PLF PLG PLH PLJ PLK PLL PLM PLP PLX PLZ PMC PMH PPA PPD PPE PPF PPG PPH PPK PPL PPM PPQ PPR PPS PPT PPU PPV PPW PPX PPY PR1 PR2 PRM PS0 PS1 PS2 PS3 PS4 PS5 Plan / Benefit Description RESERVED RX PFFS RESERVED RX PFFS STATE OF OKLAHOMA-HIGH STATE OF OKLAHOMA HIGH STATE OF OKLAHOMA HIGH STATE OF OKLAHOMA HIGH STATE OF OKLAHOMA HIGH STATE OF OKLAHOMA HIGH STATE OF OKLAHOMA HIGH STATE OF OK HIGH OPTION STATE OF OK HIGH OPTION CB STATE OF OK HIGH OPTION STATE OF OK HIGH OPTION CB STATE OF OKLAHOMA HIGH STATE OF OK HIGH OPTION STATE OF OK HIGH OPTION CB STATE OF OKLAHOMA HIGH STATE OF OKLAHOMA HIGH PAYMENT LAG PREMIUM ALLOC STATE OF OKLAHOMA HIGH STATE OF OKLAHOMA HIGH PBHI MENT/CHEM DEP-CUSTOM PBHI MENTAL HEALTH CUSTOM RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PREFERRED PLAN PREFERRED PLAN PRIME 06 MENTAL HEALTH $250 INP MNTL HLTH-HIGH (STATE) INP MENT HLTH LOW (STATE) INPATIENT PSYCH $200 INPATIENT PSYCH $300 INPATIENT PSYCH $400 341 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit PS6 PS7 PS8 PS9 PSA PSB PSC PSD PSH PSL PSM PSX PSZ PUA PUC PXA PYA PYI PZ1 PZ2 PZH PZI Q1C Q1H Q1I Q1L Q1M Q1X Q1Z Q2I Q3I QBI R01 R02 R03 R04 R10 R15 R2B R3B R4B R4C R4Z R5B R5C R5Z R6B R6C R6Z RA3 Plan / Benefit Description INPATIENT PSYCH $600 INPATIENT PSYCH 90% INPAT MEN HLTH (ST OF OK) INPATIENT PSYCH $150 INPATIENT PSYCH 100% INPATIENT PSYCH 90% STATE OF OKLAHOMA -HIGH INPATIENT PSYCH 80% STATE OF OKLAHOMA HIGH COB STATE OF OKLAHOMA HIGH STATE OF OKLAHOMA - HIGH STATE OF OKLAHOMA HIGH COB STATE OF OKLAHOMA HIGH COB SV 15-20/100A 06 SV 15-20/100A 06 CB SV 15-20/100A 06 SV 15-20/100A 06 CB RESERVED PFFS PREFERRED PLAN (COBRA) PREFERRED PLAN (COBRA) SV $15-$30/$100A PHS CB SV $15-$30/$100A PHS CB 2050 PLAN 2050 PLAN COBRA 2050 PLAN-INDIVIDUAL 2050 PLAN 2050 PLAN 2050 PLAN COBRA 2050 PLAN COBRA 2050 PLAN - INDIVIDUAL 2050 PLAN - INDIVIDUAL QUALITY BUSINESS INCENTIVE REGION LG $20-$40/$250D REGION LG $20-$40/$250D CB REGION LG $20-$40/$250D REGION LG $20-$40/$250D CB $10 $15 $7G/$14B $10G/$20B $10G/$25B $10/$250 NAT'L ACCT PLAN $10/$250 NAT'L ACCT /COBRA $10G/$20B/$40NF $10/$250 NAT'L ACCT PLAN $10/$250 NAT'L ACCT/COBRA $15G/$25B/$40NF $10/$250 NAT'L ACCT PLAN $10/$250 NAT'L ACCT/COBRA $7G/$14B 342 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit RA4 RA5 RA6 RA7 RA8 RB0 RB3 RB4 RB5 RB6 RB7 RB8 RB9 RBA RBB RBC RBD RBE RD0 RD8 RDA RDB RDC RGC RGH RGL RGM RGX RGZ RLC RLH RLL RLM RLX RLZ RM1 RM3 RM5 RM7 RM8 RMA RMB RMC RMD RME RMF RMG RMH RMI RO5 Plan / Benefit Description $10G/$20B $10G/$25B $10G/$20B/$40NF $7 $15G/$25B/$40NF $0 $3 $7G/$14B $5 $10G/$20B $10G/$25B $10G/$20B/$40NF $15G/$25B/$40NF $0 $3 $5 $10 $20 $0 $8 $5/$10/$15 $5/$10/$15 $5/$10/$15 STANDARD PLAN - GI STANDARD PLAN - GI STANDARD PLAN - GI STANDARD PLAN - GI STANDARD PLAN - GI (COBRA) STANDARD PLAN - GI (COBRA) LOW PLAN/LDDS LOW PLAN/LDDS (COBRA) LOW PLAN/LDDS LOW PLAN/LDDS LOW PLAN/LDDS LOW PLAN/LDDS $10 $3 $5 $7 $8 $10 $10 $5 $7 $8 $10 $10 $10 $15 $5 343 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit RPE RPX RR1 RRR RS0 RS4 RTA RTB RTN RX0 RX1 RX2 RX3 RX4 RX5 RX6 RX7 RX8 RXA RXB RXC RXD RXE RXF RXG RXH RXI RXJ RXK RXL RXM RXN RXP S21 S2Z S50 S52 S5Z SB2 SB3 SB4 SB5 SB6 SB7 SB8 SB9 SBQ SBR SBT SBU Plan / Benefit Description RESPITE/PERS CARE SH07 RESPITE/PERS CARE WL-SH08 LIMITEDRX LIMITEDRX $15G $10G UNIV OF TULSA UNIV OF TULSA COBRA $10G/$25B 1500 ANN.MAX. $0 $1 $2 $3 $4 $5 $6 $7 $8 $10 $10 $7 DISCOUNT $3 $5 $5 $7 $8 $10 $10 $10 $10 $15 $8 SHARE PLAN 250 5100 PLAN (COBRA) 5100 PLAN 5100 PLAN 5100 PLAN (COBRA) BOEING IAM $15/100% BOEING IAM $15/100% COBRA BOEING IAM $15/100% BOEING IAM $15/100% COBRA BANK ONE 20-30/$250A BANK ONE 20-30/$250A COBRA BANK ONE 20-30/$250A BANK ONE 20-30/$250A COBRA SV 15/250A BOEING 06 SV 15/250A BOEING 06 SV 15/250A BOEING 06 SV 15/250A BOEING 06 344 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit SC1 SC2 SC3 SCH SD1 SD2 SD3 SER SF2 SF3 SF4 SF5 SFC SFD SFF SFG SFH SFI SGC SGH SGL SGM SGX SGZ SH0 SH2 SH3 SH4 SH5 SH6 SH7 SH8 SHC SHD SHG SHH SHZ SKR SLR SMI SO1 SO2 SO3 SOK SOO SOP SOT SP1 SR1 SR2 Plan / Benefit Description SH-MCDONNELL DOUGLAS - C SH-MCDONNELL DOUGLAS - C SH-MCDONNELL DOUGLAS - C *OK TO USE* ENTRD IN ERROR SH-MCDONNELL DOUGLAS - D PH-MCDONNELL DOUGLAS - D SH-MCDONNELL DOUGLAS - D SUPP ELIGIBILITY STATE FARM 20-30/250A STATE FARM 20-30/250A CBRA STATE FARM 20-30/250A STATE FARM 20-30/250A CBRA SPLIT FAMILY COVERAGE $10/$30/$60 SF SV 20-30/250A STATEFARM SV 20-30/250A STATEFARM CB SV 20-30/250A STATEFARM SV 20-30/250A STATEFARM CB BASIC PLAN GI BASIC PLAN GI (COBRA) BASIC PLAN GI BASIC PLAN GI BASIC PLAN GI (COBRA) BASIC PLAN GI SECURE HORIZONS STANDARD SECURE HORIZONS-PART B TULSA SH STANDARD PLAN OK CITY SH STANDARD OK SH STANDARD PLAN OK SH STANDARD PLAN OK SH STANDARD PLAN OK SH STANDARD PLAN SH STANDARD - OKC SECURE HORIZONS-PART B OK SH PART B OK SH PART B SECURE HORIZONS-PT B ONLY SV 25-40/500A STFRM 08 SV 25-40/500A STFRM 08 CB SMI CORE I/P & O/P EFF1-00 STATE OF OKLAHOMA PLAN STATE OF OKLAHOMA PLAN 2 STATE OF OKLA. 1992 15-30/150D STATE OK GR07 15-30 ST OK NO-AARP GR08 15-30 ST OK NO-AARP GR08 15-30/150D STATE OK GR07 SUPPLEMENTAL LIFE BENE UAW RETIREE SECURE HORIZON UAW RETIREE SECURE HORIZON 345 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit SSP SSR ST1 ST2 STA STB STD STF STK STM STP STQ STZ SXR SYR SZ1 SZ2 SZ3 SZO T3P T4P TA1 TA2 TAX TB3 TBI TBO TBQ TBU TBV TBW TBX TBY TC6 TCE TCN TG6 TG7 TG9 TGD TGE TGN TGO TGP TJ6 TJ7 TJ9 TJD TJE TJN Plan / Benefit Description SH SILVER SNEAKERS SLV SNEAK/FITNESS BEN GR06 STANDARD PLAN STANDARD PLAN SV 20-35/200A OK 06 SV 20-35/200A OK 06 CB RESERVED FOR PPO LIFE SV 20-35/200A OK 06 SV 20-35/200A OK 06 CB SV 20-50/500D 06 SV 20-50/500D 06 CB SV 20-50/500D 06 SV 20-50/500D 06 CB SV 25-40/500A STFRM 08 SV 25-40/500A STFRM 08 CB STANDARD PLAN (COBRA) STANDARD PLAN (COBRA) STATE OF OKLA. 1992 STATE OF OKLA. COBRA) 15-20/100A GR06 5-10/100% GR06 TULSA AREA-SH INDIVIDUAL TULSA-SH INDIV.PRT B ONLY TAX PCOK PREMIUM TAX $3G/$7B ARP MCC TULSA EP-PL SH08 ARP MCC TULSA PL-DLX SH08 ARP MCC TULSA PP-PL SH08 ARP MCC TULSA PP SH08 ARP MCC TULSA PLUS SH08 ARP MCC TULSA SH08 ARP MCC TULSA DLX SH08 ARP MCC TULSA EP SH08 15/30 TULSA C SH06 D466 15/30 TULSA C SH06 EPO 15/30 TULSA C SH06 MCC TULSA PP-PL SH07 MCC TULSA EP-PL SH07 MCC TULSA PLUS SH07 MCC TULSA DELUXE SH07 MCC TULSA EP SH07 MC COMP TULSA SH07 MCC TULSA PL-DLXE SH07 MCC TULSA PP SH07 MCC ESS TULSA PP-PL SH07 MCC ESS TULSA EP-PL SH07 MCC ESS TULSA PLUS SH07 MCC ESS TULSA DELUXE SH07 MCC ESS TULSA EP SH07 MC COMP ESS TULSA SH07 346 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit TJO TJP TLC TLH TLL TLM TLX TLZ TM3 TM5 TMA TMB TMC TMD TMP TP3 TP4 TPH TPL TR5 TS1 TS2 TX3 TX5 TXA TXB TXC TXD TXE TXF TXG TXH TXI TXJ TXK TXL TXM TXN TXO TXP TXQ TXR TXS TZ1 U01 U02 U03 U04 U05 U06 Plan / Benefit Description MCC ESS TULSA PL-DLXE SH07 MCC ESS TULSA PP SH07 HIGH PLAN/LDDS HIGH PLAN/LDDS (COBRA) HIGH PLAN/LDDS HIGH PLAN/LDDS HIGH PLAN/LDDS (COBRA) HIGH PLAN/LDDS (COBRA) $3/$8/$13 $5/$10/$15 $3/$8/$13 $5/$10/$15 $5/$10/$15 20%/40% 20%/40% TOWERS PERRIN $15 PLAN TOWERS PERRIN $15 PLAN 5-10/100% GR06 15-20/100A GR06 SH GRP RET $5/100% 2001 TULSA STANDARD PLAN TULSA STNDRD PART B ONLY $3/$8/$13 $5/$10/$15 $5/$10/$15 $5/$10/$15 $5/$10 $5/$10/$15 $5G/$10B $10G/$20B $3/$8/$13 $5/$10/$15 $5/$10/$15 $5/$10/$15 20%/40% $3G/$7B $5G/$10BR $10G/$20B $600 BRND MAX. $10G/$20B 20%/40% $5/$10/$15 $15G/$30B $5/$10 SHARE PLAN 250 (COBRA) USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO 347 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit U07 U08 U09 U10 U11 U12 U13 U14 U15 U16 U17 U18 U19 U20 U21 U22 U23 U24 U25 U26 U27 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U42 U43 U44 U45 U46 U47 U48 U49 U50 U51 U52 U53 U54 U55 U56 Plan / Benefit Description USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY VSUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO 348 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit U57 U58 U59 U60 UFA UGA UHA UHC UJA UTC UZ1 UZ2 UZF V15 V1P V1Y V27 V2F V8P V8Q V8R V8S V8T V8U V8V V8W V8X VB6 VBD VBH VCC VCK VCV VCZ VDA VFP VFQ VG6 VGP VGQ VH0 VH1 VH2 VH3 VH4 VH5 VH6 VHC VHD VJM Plan / Benefit Description USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO SV 20-40/250D 07 SV 20-40/250D 07 CB SV 20-40/250D 07 DUAL-OPTION - UHC 06 SV 20-40/250D 07 CB TAKING CHARGE OF YOU NEW SHARE PLAN (COBRA) NEW SHARE PLAN (COBRA) OPT SHARE PLAN (COBRA) VISION CARE $15 (VSP) ADVANTAGE PLAN OPTION ADVANTAGE PLAN OPTION CBR SC 20 ELIGIBILITY ONLY 25/70A TOWERS GR-VN06 VSP 0 REFRAC 1/V YR VN-GR08 5 REFRAC 1/V YR VN-GR08 10 REFRAC 1/V YR VN-GR08 15 REFRAC 1/V YR VN-GR08 20 REFRAC 1/V YR VN-GR08 25 REFRAC 1/V YR VN-GR08 30 REFRAC 1/V YR VN-GR08 35 REFRAC 1/V YR VN-GR08 40 REFRAC 1/V YR VN-GR08 25/150A 2 YRS SH-VN06 0/0 BOEING IAM GR VN06 COL $15/$75 BOEING HRLY GP RET COALITION LOW PLAN POS-COALITION LOW PLAN POS-COALITION LOW (COBRA) COALITION LOW PLAN - COBRA 15/70A GR-VN07 0/75A 2YRS VN-GR08 0/125A 2YRS VN-GR08 25/75A VN-GR06 5/75A 2YRS VN-GR08 5/125A 2YRS VN-GR08 PC VISION CARE - HIGH VISION $0 COPAY VHO RIDER VISION $5 COPAY VHO RIDER VISION $10 COPAY VHO RIDER VISION $15 COPAY VHO RIDER VISION $20 COPAY VHO RIDER VISION $25 COPAY VHO RIDER VISION $10 EXAM - VSP VISION $15 EXAM - VSP 0/0 BOEING IAM VN-GR08 349 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit VJP VJQ VKP VM0 VMP VMQ VN1 VN2 VN3 VN5 VNQ VP6 VPE VPP VQC VQD VQJ VQP VQR VS0 VS1 VS2 VS3 VS4 VS5 VS6 VSK VSQ VSX VV1 VV2 VV3 VV4 VV5 VV6 VV7 VVP VVQ VWP WAP WBC WBM WBX WBZ WEL WKC WKH WKL WKM WKX Plan / Benefit Description 20/100M JPM-COLE 10/75A 2YRS VN-GR08 10/125A 2YRS VN-GR08 VISION (MCDONNELL DOUGLAS) 15/12V VN06 VSP 15/125A 2YRS VN-GR08 GRP RET $5OV/$125 ALLOWNCE GRP RET $10OV/$75 ALLOWNCE 15/75A GR-VN05 COLE GRP RET $20V/$75 ALLOWANCE 20/75A 2YRS VN-GR08 ADVANCE WELLNESS SH-WL06 RESERVED PFFS 20/125A 2YRS VN-GR08 15/130A 1YR DLX VN-SH08 30/70A 2YRS VN-SH08 5/100A 2YRS VN-SH08 25/70A 2YRS VN-GR08 0/70A 2YRS VN-SH08 PC VISION CARE - STANDARD VISION $0 COPAY VSO RIDER VISION $5 COPAY VSO RIDER VISION $10 COPAY VSO RIDER VISION $15 COPAY VSO RIDER VISION $20 COPAY VSO RIDER VISION $25 COPAY VSO RIDER 5/100A 2YRS SH-VN07 30/70A 2YRS SH-VN07 15/130A 1YR DLX SH-VN07 VISION STANDARD $0 COPAY VISION STANDARD $5 COPAY VISION STANDARD $10 COPAY VISION STANDARD $15 COPAY VISION STANDARD $20 COPAY VISION STANDARD $25 COPAY VISION STANDARD $30 COPAY 15/75A 2YRS VN-GR08 25/75A 2YRS VN-GR08 25/125A 2YRS VN-GR08 RESERVED WT ALT PROGRAMS MOBIL PLAN MOBILE PLAN MOBIL PLAN COBRA MOBIL PLAN COBRA SUPPLEMENTAL WELLNESS STATE OF OKLAHOMA LOW STATE OF OKLAHOMA LOW STATE OF OKLAHOMA LOW STATE OF OKLAHOMA LOW STATE OF OKLAHOMA LOW 350 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit WKZ WLC WLD WLE WLF WLG WLH WLJ WLK WLL WLM WLX WLZ WMC WMM WMX WMZ WPR WPS WPT WQR WQS WQT WRR WRS WRT WS1 WS2 WS3 WS4 WS5 WS6 WSC WSH WSL WSM WSP WSQ WSX WSZ WUR WUS WUT WVR WVS WVT WXR WXS WXT X10 Plan / Benefit Description STATE OF OKLAHOMA LOW STATE OF OKLAHOMA LOW STATE OF OK LOW OPTION STATE OF OK LOW OPTION CBR STATE OF OK LOW OPTION STATE OF OK LOW OPTION CBR STATE OF OKLAHOMA LOW STATE OF OK LOW OPTION STATE OF OK LOW OPTION CBR STATE OF OKLAHOMA LOW STATE OF OKLAHOMA LOW STATE OF OKLAHOMA LOW STATE OF OKLAHOMA LOW MOBIL PLAN MOBIL PLAN MOBIL PLAN (COBRA) MOBIL PLAN (COBRA) 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 WILLIAM SONOMA $20/100A WILLIAM SONOMA $20/100A CB WILLIAM SONOMA $20/100A WILLIAM SONOMA $20/100A CB SV 20/100A WS 05 SV 20/100A WS 05 CB LOW PLAN-ST OF OKLAHOMA LOW PLAN-ST OF OK (COBRA) LOW PLAN-ST OF OKLAHOMA LOW PLAN-ST OF OKLAHOMA SV 20/100A WS 05 SV 20/100A WS 05 CB LOW PLAN-ST OF OK (COBRA) LOW PLAN-ST OF OK (COBRA) 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 $10 351 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit X15 XA7 XAF XKE XMK XML XMM XMN XMO XMP XMQ XMR XMS XMT XMU XMV XXX Y1K Y1V Y2K Y2V YCC YCK YCV YCZ YXA YXJ YYA YYB YZC Z2P Z2T Z2U Z2X Z5R Z5T Z5U Z5V Z8F Z8P Z8X ZA2 ZA3 ZA4 ZA5 ZA6 ZA7 ZA8 ZA9 ZB2 Plan / Benefit Description $15 $7 $5G/$15B SVA 1530/250A SG07 $10 $5GF/$10BF $5GF/$15BF $10GF/$15BF $10GF/$25BF $5/$10/$25 $10GF/$15BF $10GF/$25BF $5G/$10B $5GF/$10BF $5/$10/$25 $5GF/$10BF PREMIUM ALLOCATION KP400 - AAON CUSTOM PLAN KP400 - AAON COBRA CUSTOM KP500 KEY PLAN KP500 KEY PLAN COBRA COALITION HIGH PLAN POS-COALITION HIGH PLAN POS-COALITION HIGH (COBRA) COALITION HIGH PLAN-COBRA SV 35/240A W/BH9 06 SV 35/240A W/BH9 06 CB SV 35/240A W/BH9 06 SV 35/240A W/BH9 06 CB DUMMY CODE 10-15/50A T1A NON-AARP GR8 15-25/200D T3A NO-AARP GR8 15-25/200D T3A NO-AARP GR8 10-15/50A T1A NON-AARP GR8 15-25/130D T2B NO-AARP GR8 15-30/220D T3B NO-AARP GR8 15-30/220D T3B NO-AARP GR8 15-25/130D T2B NO-AARP GR8 880 PLAN OPT COBRA 10-20/200A T1C NO-AARP GR8 10-20/200A T1C NO-AARP GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 352 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit ZB3 ZB4 ZB5 ZB6 ZB7 ZB8 ZB9 ZC2 ZC3 ZC4 ZC5 ZC6 ZC7 ZC8 ZC9 ZD2 ZD3 ZD4 ZD5 ZD6 ZD7 ZD8 ZD9 ZE2 ZE3 ZE4 ZE5 ZE6 ZE7 ZE8 ZE9 ZF2 ZF3 ZF4 ZF5 ZF6 ZF7 ZF8 ZF9 ZG2 ZG3 ZG4 ZG5 ZG6 ZG7 ZG8 ZG9 ZH2 ZH3 ZH4 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 353 of 640 Plan Benefit - OK State OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK Plan / Benefit ZH5 ZH6 ZH7 ZH8 ZH9 ZJ2 ZJ3 ZJ4 ZJ5 ZJ6 ZJ7 ZJ8 ZJ9 ZK2 ZK3 ZK4 ZK5 ZK6 ZK7 ZK8 ZK9 ZM2 ZM3 ZM4 ZM5 ZM6 ZM7 ZM8 ZM9 ZN2 ZN3 ZN4 ZN5 ZN6 ZN7 ZN8 ZN9 ZP2 ZP3 ZP4 ZP5 ZP6 ZP7 ZP8 ZP9 ZR2 ZR3 ZR4 ZR5 ZR6 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 354 of 640 Plan Benefit - OK State OK OK OK OK Plan / Benefit ZR7 ZR8 ZR9 ZZZ Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO HISTORICAL PLAN 355 of 640 Plan Benefit - OR Cap/Eligibility CP7810 Assigned Plan Benefit Codes & Descriptions State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 1BS 1C1 1C2 1OS 1Z2 2AL 2AN 2AT 2AY 2BL 2C1 2C4 2CA 2CJ 2CK 2FH 2FL 2GH 2HH 2JH 2KH 2MH 2MN 2NH 2ON 2PH 2QD 2QH 2S1 2S2 2S3 2S4 2S5 2S6 2S7 2S8 2S9 2SA 2SB 2SC 2SD 2SE Plan / Benefit Description 15 SH-RX05 $7/$7 $5G/$5B UMTA $9G SH SHARE PLAN (PACIFICARE EE) 5/10 RX 06 4/20/40 LO GR-RX07 5/15 RX 06 4/25/50 HI GR-RX07 10/25/50 RX-GR08 $7.50G/$15B $5G/$15B AT&T $5G/$15B $5G/$15B $10G/$20B 4/15/30 RX-GR08 5/20/45 RX-GR08 4/20/40 RX-GR08 4/15/30 RX-GR08 4/20/40 RX-GR08 4/25/50 RX-GR08 4/25/45 RX-GR08 ALREADY USED 4/28/55 RX-GR08 POS OUT OF NETWORK 4/28/58 RX-GR08 OK TO USE CODE FOR CO 33 4/25/50 RX-GR08 $5G/$10B $5G/$15B $5G/$20B $5G/$25B $10G/$20B $10G/$25B $10G/$35B $5G/$5B $25B/$25G $15G/$40B WA RX DONT USE IN OR $10/$20 $10/$25 WA RX DONT USE IN OR 356 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 2SF 2SH 2SJ 2U1 2U2 2U3 2U4 2U5 2U6 2U7 2U8 2U9 2UA 2UB 2UC 2UD 2UE 2UF 2UH 2UK 2UL 2UM 2UN 2UO 2UP 2UQ 2VH 2WH 2XH 2YH 2ZA 2ZB 2ZC 2ZD 2ZE 2ZF 39C 3B4 3C1 3C2 3C3 3C4 3C6 3C7 3C8 3C9 3CB 3CF 3CX 3CY Plan / Benefit Description $10/$35 $15/$40 RESERVED RX LOW $5G/$10B $5G/$15B $5G/$20B $5G/$25B $10G/$20B $10/$25 $10G/$35B $5G/$15B $10G/$35B $15G/$25B $5G/$15B $15G/$35B $10G/$20B $10G/$20B $10G/$25B 10/25/50 RX-GR08 $5/$10 W/INF $5/$15 W/INF $10/$20 W/INF 10/25 W/INF $10/$35 W/INF $15/$25 W/INF $15/$35 W/INF 10/25/50 RX-GR08 5/20/45 RX-GR08 5/20/45 RX-GR08 4/10/20 RX-GR08 0/0 GR-RX07 2/40 GR-RX07 5/25 GR-RX07 5/65 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 WA RX DONT USE IN OR 5G/15B/30NF GRP RT $10/$15/$30 DO NOT USE DUP TO C COUNTY $5G/$15B/$30NF WA RX DONT USE IN OR $10G/$25B/$50NF $10G/$20B/$35NF WA RX DONT USE IN OR $10G/$20B/$40NF $5G/$15B/$30NF $20G/$40B/$50NF 10G/20B/40NF PEPSI 10G/20B/35NF I VBA 357 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 3D1 3D2 3D3 3D4 3D5 3D6 3D7 3D8 3DC 3DR 3EA 3FC 3FD 3GA 3GB 3HA 3HC 3HP 3PA 3PC 3PH 3QB 3QD 3QU 3S1 3S2 3S3 3S4 3S5 3S6 3S7 3S8 3S9 3SA 3SB 3SC 3SD 3SE 3SF 3SH 3SJ 3SK 3SP 3SU 3SV 3TA 3TB 3U1 3U2 3U3 Plan / Benefit Description $15G/$25B/$40NF $100 DED $15G/$25B/$40NF $200 DED $15/30/50/100D E $15/35/60/200D E 15/25/40 100D 15/25/40 200D 15/30/50 100D E 15/35/60 200D E 10G/20B/35NF SCHWB 10/25/40 RX06 RESERVED FIDELITY RX 06 10/30/50 RX05 15/30/60 RX06 SF $15G/$25B/$40NF 15G/25B/40NF W/INJ 10/30/45 RX 06 $10G/$25B/$40NF HP 5/30/45 GR-RX07 10/20/40 RX 06 10G/30B/40NF E W/I 10/30/50 RX06 UN USED WRONG STATE 20/40/60 RX06 20/40/60/1000D RX6 $3/$8/$23 $8/$13/$28 $15/$25/$40 $7/$12/$27 $3G/$8B/$23NF $5G/$10B/$25NF $8G/$13B/$28NF $10G/$15B/$30NF $15G/$25B/$40NF RX RESERVED $10G/$20B/$30NF $10G/$20B/$45NF E $10G/$30B/$50NF E $15G/$25B/$50NF E 5/10/25 RX 06 10/20/45 E $10/$30/$50 E $15/$25/$50 E 10/15/30 RESERVED RX PREVAILING 15/25/40 10/20/45 RX 05 15/30/50 RX 08 OR RX CODE DONT USE IN WA OR RX CODE DONT USE IN WA $10/$15/$30 358 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 3U4 3U5 3U6 3U7 3U8 3U9 3UA 3UB 3UC 3UD 3UE 3UF 3UG 3UH 3UI 3UO 3UP 3UQ 3UR 3US 3UT 3UU 3UW 3UX 3VA 3W3 3W4 3W5 3W6 3ZE 3ZF 3ZG 3ZH 3ZJ 3ZK 3ZL 3ZM 40A 40B 40C 40D 40E 40F 40G 40H 40I 40J 40K 40L 40M Plan / Benefit Description OR RX AVAL DONT USE IN WA $5/$10/$25 $3G/$8B/$23NF $5G/$10B/$25NF $8G/$13B/$28NF $10G/$15B/$30NF $15G/$25B/$40NF $10G/$20B/$30NF $10G/$25B/$40NF $10G/$25B/$50NF $10/20/45 W/INF E $10/30/50 W/INF E $15/25/50 W/INF E OR RX AVAL DONT USE IN WA OR RX AVAL DONT USE IN WA 5/10/25 W/INF 10/15/30 W/INF 15/25/40 W/INF 10/20/30 W/INF 10/25/40 W/INF 10/25/50 W/INF 10/20/45 W/INF E 10/30/50 W/INF E 15/25/50 W/INF E 15/25/50 RX 08 $15/30/50/100D I E $15/35/60/200D I E 15/30/50 100D I E 15/35/60 200D I E 5/10/20 GR-RX07 10/20/35 GR-RX07 10/20/35 GR-RX07 10/25/55 GR-RX07 10/40/75 GR-RX07 7/20/50% GR-RX07 2/30/60 GR-RX07 10/25/50 GR-RX07 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 359 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 40N 40O 40P 40Q 40R 40S 40T 40U 40V 40W 40X 40Y 40Z 41B 41C 41D 41E 41F 41G 41H 41I 41J 41K 41L 41M 41N 41O 41P 41Q 41R 41S 41T 41U 41V 41W 41X 41Y 41Z 440 49I 4A0 4A1 4AI 4AO 4B0 4B1 4BI 4BO 4C0 4C1 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 360 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 4CI 4CO 4D0 4D1 4E0 4E1 4EI 4EO 4F0 4F1 4FI 4FO 4G0 4G1 4GI 4H0 4H1 4HI 4HO 4I0 4I1 4IA 4IB 4IC 4ID 4IE 4IF 4IG 4IH 4II 4IJ 4IK 4IL 4IN 4IO 4IP 4IQ 4IR 4IS 4IT 4IU 4IV 4IW 4IX 4IY 4IZ 4J0 4J1 4JI 4JO Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 361 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 4K0 4K1 4KI 4KO 4L0 4L1 4LI 4M0 4M1 4MI 4MO 4N0 4N1 4NI 4NO 4O0 4O1 4OA 4OB 4OC 4OD 4OF 4OH 4OI 4OJ 4OK 4OL 4OM 4OO 4OP 4OQ 4OS 4OT 4OU 4OV 4OW 4OX 4OY 4OZ 4P0 4P1 4PI 4PO 4Q0 4Q1 4QI 4QO 4R0 4R1 4RO Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 362 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 4S0 4S1 4T0 4T1 4TI 4U0 4U1 4UI 4UO 4V0 4V1 4VI 4VO 4W0 4W1 4WI 4WO 4X0 4X1 4XI 4XO 4Y0 4Y1 4YI 4YO 4Z0 4Z1 4ZI 4ZO 50A 50B 50C 50D 50E 50F 50G 50H 50I 50J 50K 50L 50M 50N 50O 50P 50Q 50R 50S 50T 50U Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 363 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 50V 50W 50X 50Y 50Z 51A 51B 51C 51D 51E 51F 51G 51H 51I 51J 51K 51L 51M 51N 51O 51P 51Q 51R 51S 51T 51U 51V 51W 51X 51Y 51Z 52I 535 536 537 538 539 53I 540 541 542 543 544 545 546 547 548 549 54I 550 Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO 364 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 551 552 553 554 555 556 557 558 559 55I 560 561 562 563 564 565 566 567 568 569 56I 570 571 572 573 574 575 576 577 578 579 57I 580 581 582 583 584 585 586 587 588 589 58I 590 591 592 593 594 59I 5A0 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVE DPPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 365 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 5A1 5AI 5AO 5B0 5BI 5BO 5C0 5C1 5CI 5CO 5D0 5D1 5E0 5E1 5EI 5F0 5F1 5FI 5FO 5G0 5G1 5GI 5H0 5H1 5HI 5HO 5I0 5I1 5IA 5IB 5IC 5ID 5IE 5IF 5IG 5IH 5II 5IJ 5IK 5IL 5IN 5IO 5IP 5IQ 5IR 5IS 5IU 5IV 5IW 5IX Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 366 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 5IY 5IZ 5J0 5J1 5JI 5JO 5K0 5K1 5KI 5KO 5L0 5L1 5LI 5M0 5M1 5MI 5N0 5N1 5NI 5NO 5O0 5O1 5O2 5O3 5O4 5O5 5O6 5O7 5O8 5O9 5OA 5OB 5OD 5OF 5OH 5OI 5OJ 5OK 5OL 5OM 5ON 5OO 5OQ 5OS 5OT 5OU 5OV 5OW 5OX 5OY Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 367 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 5OZ 5P0 5P1 5PI 5PO 5Q0 5Q1 5QI 5QO 5R0 5RO 5S0 5T0 5T1 5TI 5U0 5U1 5UI 5UO 5V0 5V1 5VI 5VO 5W0 5W1 5WI 5WO 5X0 5X1 5XI 5XO 5Y0 5Y1 5YI 5YO 5Z0 5Z1 5Z2 5ZI 5ZO 600 601 602 603 604 605 606 607 608 609 Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO STANDARD 5 PLAN (COBRA) RESERVED BENEFIT PPO RESERVED BENEFIT PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO 368 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 Plan / Benefit Description MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED PPO RIDER PPO MANDATED OFFER RIDER PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 369 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 6AH 6AL 6BH 6BL 6CD 6DH 6DL 6EH 6EL 6FH 6FL 6GP 6HH 6HL 6HR 6JH 6JL 6JP 6KH Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 0/0 HI GR-RX07 0/0 LO GR-RX07 2/30/06 HI GR-RX07 2/30/60 LO GR-RX07 7/14 GR-RX06 2/40 HI GR-RX07 2/40 LO GR-RX07 5/25 HI GR-RX07 5/25 LO GR-RX07 5/65 HI GR-RX07 5/65 LO GR-RX07 8.50/26.45/50% SH6 5/10 HI GR-RX07 5/10 LO GR-RX07 10/20 GR-RX06 5/10/20 HI GR-RX07 5/10/20 LO GR-RX07 8.50/26.70/50% SH6 7/14 HI GR-RX07 370 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 6KL 6LH 6LL 6MA 6MH 6ML 6NH 6NL 6NM 6PH 6PL 6PM 6QH 6QL 6RH 6RL 6SH 6SI 6SL 6SR 6TH 6TL 6TR 6UH 6UL 6UR 6VM 6WH 70O 710 711 712 713 714 715 716 717 718 719 71A 71B 71C 71D 71E 71F 71G 71H 71I 71J 71K Plan / Benefit Description 7/14 LO GR-RX07 7/20/50% HI GR-RX7 7/20/50% LO GR-RX7 10/25%/40% RX-GR06 10/20 HI GR-RX07 10/20 LO GR-RX07 10/20/40 HI GR-RX7 10/20/40 LO GR-RX7 5/15/30 GR-RX06 10/20 HI GR-RX07 10/20 LO GR-RX07 5/15/30 GR-RX06 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 10/25/55 HI GR-RX7 10/20/40 I GR-RX06 10/25/55 LO GR-RX7 10/20/40 GR-RX06 10/40/75 HI GR-RX7 10/40/75 LO GR-RX7 10/25/40 GR-RX06 15/25/40 HI GR-RX7 15/25/40 LO GR-RX7 15/25/40 GR-RX06 5/5 GR-RX06 10/25/50 HI GR-RX7 VALUE $25/70% SG RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 371 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 71L 71M 71N 71O 71P 71Q 71R 71S 71T 71U 71V 71W 71X 71Y 71Z 720 721 722 723 724 725 726 727 728 729 72A 72B 72C 72D 72E 72F 72G 72H 72I 72J 72K 72L 72M 72N 72O 72P 72Q 72R 72S 72T 72U 72V 72W 72X 730 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO 372 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 731 732 733 734 735 736 737 738 739 73A 73B 73C 73D 73E 73F 73G 73H 73I 73J 73K 73L 73M 73N 73O 73P 73Q 73R 73S 73T 73U 73V 73W 73X 73Y 73Z 740 741 742 743 744 745 746 747 748 749 74A 74B 74C 74D 74E Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 373 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 74F 74G 74H 74I 74J 74K 74L 74M 74N 74O 74P 74Q 74R 74S 74T 74U 74V 74W 74X 74Y 74Z 750 751 752 753 754 755 756 757 758 759 75A 75B 75C 75D 75E 75F 75G 75H 75I 75J 75K 75L 75M 75N 75O 75P 75Q 75R 75S Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 374 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 75T 75U 75V 75W 75X 75Y 75Z 760 761 762 763 764 765 766 767 768 769 76A 76B 76C 76D 76E 76F 76G 76H 76I 76J 76K 76L 76M 76N 76O 76P 76Q 76R 76S 76T 76U 76V 7AQ 7AR 7BD 7BH 7BI 7BL 7BR 7C1 7C2 7CD 7CI Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 7/20 GR-RX07 0/0 GR-RX07 7/14 GR-RX07 4/10/20 T1A H GRX7 7/14 I GR-RX07 4/10/20 T1A L GRX7 0/0 FLAT GR-RX07 NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 7/14 GR-RX07 7/14 I GR-RX07 375 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 7CM 7DD 7DH 7DL 7DM 7DR 7ED 7EH 7EL 7EM 7ER 7FD 7FH 7FL 7FM 7FR 7GD 7GM 7GR 7HH 7HI 7HL 7HR 7JH 7JL 7JM 7JR 7KH 7KI 7KL 7KM 7KR 7LH 7LL 7LM 7LR 7MA 7MH 7MI 7ML 7MR 7NH 7NL 7NM 7O1 7O2 7OZ 7PH 7PI 7PL Plan / Benefit Description 15/25/40 GR-RX07 7/20/30 GR-RX07 4/15/30 T1B H GRX7 4/15/30 T1B L GRX7 15/25/40 GR-RX07 10/10 FLAT GR-RX07 7/7 GR-RX07 4/20/40 T1C H GRX7 4/20/40 T1C L GRX7 3/3 FLAT GR-RX07 10/20 GR-RX07 7/7 C GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 3/3/3 GR-RX07 10/20 GR-RX07 10/20/30 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 4/15/30 T2A H GRX7 10/20 I GR-RX07 4/15/30 T2A L GRX7 10/20 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/10 GR-RX07 10/10 GR-RX07 4/28/55 T3B H GRX7 10/20/35 I GR-RX07 4/28/55 T3B L GRX7 5/10/20 GR-RX07 10/20/35 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 5/15 GR-RX07 15/25/40 GR-RX07 10/25%/40% GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 10/20/40 GR-RX07 4/25/50 T2C H GRX7 4/25/50 T2C L GRX7 5/15/30 GR-RX07 $25/70% SG $25/70% SG COBRA VALUE $25/70% SG COBRA 4/25/50 T2C H GRX7 10/20/40 I GR-RX07 4/25/50 T2C L GRX7 376 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 7PM 7PR 7QH 7QI 7QL 7QM 7QR 7RA 7RB 7RC 7RD 7RH 7RL 7RM 7RR 7SB 7SI 7SR 7TH 7TL 7TM 7TR 7UH 7UL 7UM 7UR 7VH 7VL 7VM 7WH 7WI 7WL 7WM 7WR 7XA 7XB 7XC 7XD 7XE 7XF 7XG 7XH 7XJ 7XL 7XM 7XP 7YH 7YI 7YL 7YM Plan / Benefit Description 5/15/30 GR-RX07 10/20/40 GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 4/15/30 T2A H GRX7 4/15/30 T2A L GRX7 5/15/30 GR-RX07 15/35/50/50 GR-X07 10/25%/40% GR-RX07 10/20/40 I GR-RX07 10/20/40 GR-RX07 4/28/55 T3B H GRX7 4/28/55 T3B L GRX7 5/5 GR-RX07 10/25/40 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/5 GR-RX07 15/25/40 GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 5/5 GR-RX07 4/20/40 T1C H GRX7 15/25/40 I GR-RX07 4/20/40 T1C L GRX7 5/7.50 GR-RX07 15/25/40 GR-RX07 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/25/50 RDS GR-RX7 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/15/30 T1B H GRX7 4/25/50 RDS GR-RX7 4/15/30 T1B L GRX7 7/14 GR-RX07 5/29/60 N/G SH-RX7 4/10/20 T1A H GRX7 15/25/40 I GR-RX07 4/10/20 T1A L GRX7 7/14 GR-RX07 377 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 7YR 7ZH 7ZL 7ZM 7ZR 80O 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 84A 84B 84C 84D Plan / Benefit Description 15/25/40 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 VALUE $20/80% SG RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO VESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 378 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 84E 84F 84G 84H 84J 84K 84L 84M 84N 84P 84Q 84R 84S 84T 84U 84V 84W 84X 84Y 84Z 850 851 852 853 854 855 856 857 858 859 85A 85B 85C 85D 85E 85F 85G 85H 85J 85K 85L 85M 860 861 862 863 864 865 866 867 Plan / Benefit Description 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 379 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 868 869 881 882 8AH 8AR 8B8 8BH 8C1 8C2 8CH 8DD 8DH 8DR 8ED 8EH 8EM 8ER 8FD 8FH 8GH 8GM 8HD 8HH 8KM 8LH 8LM 8MA 8NM 8O1 8O2 8OZ 8PH 8PM 8RH 8RM 8SH 8TH 8TM 8TR 8UM 8UR 8VM 8WH 8Z1 8Z2 90O 910 911 912 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO 880 PLAN 880 PLAN (2) 0/0 HI C GR-RX07 0/0 C GR-RX07 5/29/60NG RX-SH08 DO NOT USE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 2/30/60 HI C GRX07 7/20/30 C GR-RX07 2/40 HI C GR-RX07 10/10 FLAT C GRX07 7/7 C GR-RX07 5/25 HI C GR-RX07 3/3 FLAT C GR-RX07 10/20 C GR-RX07 7/7 C GR-RX07 5/65 HI C GR-RX07 510 HI C GR-RX07 5/10 C GR-RX07 10/20/30 C GR-RX07 DO NOT USE 5/10/20 C GR-RX07 7/20/50% HI C GRX7 5/15 C GR-RX07 10/25%/40% C GRX07 5/15/30 C GR-RX07 $20/80% SG $20/80% SG COBRA VALUE $20/80% SG COBRA 10/20 HI C GR-RX07 5/15/30 C GR-RX07 10/20/35 HI C GRX7 5/15/30 C GR-RX07 10/25/55 HI C GRX7 10/40/75 HI C GRX7 5/5 C GR-RX07 10/25/40 C GR-RX07 5/5 C GR-RX07 15/25/40 C GR-RX07 5/7.50 C GR-RX07 10/25/50 HI C GRX7 880 PLAN (COBRA) 880 PLAN (2) VALUE $15/90% SG RESERVED PPO RESERVED PPO RESERVED PPO 380 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 913 914 915 916 917 918 919 91H 920 921 922 923 924 925 926 927 928 929 92H 930 931 932 933 934 935 936 937 938 939 93H 940 941 942 943 944 945 946 947 948 949 94H 950 951 952 953 954 955 956 957 958 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15/25/40 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/25/50 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20/40 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20 HI RX-GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 381 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 959 95H 960 961 962 963 964 965 966 967 968 969 970 971 972 974 975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 9AN 9AQ 9AR 9AY 9BE 9BH 9BL 9C1 9C2 9CM 9DH 9DL 9DR 9EH Plan / Benefit Description RESERVED PPO 10/40/75 HI C XGR8 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 4/20/40 LO RX-GR08 7/20 RX-GR08 0/0 RX-GR08 4/25/50 HI RX-GR08 7/14 RX-GR08 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 15/25/40 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 10/10 FLAT C XGR08 4/20/40 T1C H XGR8 382 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 9EL 9ER 9FD 9FH 9FL 9GE 9GM 9HD 9HH 9HK 9HL 9HN 9HP 9JH 9JL 9KH 9KL 9KS 9LH 9LL 9LM 9LP 9LV 9MA 9MH 9MI 9ML 9MR 9NH 9NL 9NM 9O1 9O2 9OZ 9PH 9PL 9QH 9QL 9RH 9RL 9RP 9RS 9RX 9TH 9TL 9UH 9UL 9VH 9VL 9VM Plan / Benefit Description 4/20/40 T1C L XGR8 10/20 RX-GR08 7/7 C RX-GR08 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 10/20/30 RX-GR08 5/10 RX-GR08 10/20/30 C RX-GR08 4/15/30 T2A H XGR8 4/10/20 RX-GR08 4/15/30 T2A L XGR8 4/15/30 RX-GR08 5/30/45 RX-GR08 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 10/20/35 RX-GR08 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 5/15 C RX-GR08 5/15 RX-GR08 10/20/35 RX-GR08 10/25%/40% RX-GR08 4/20/40 T2B H XGR8 10/20/40 I RX-GR08 4/20/40 T2B L XGR8 10/20/40 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/15/30 RX-GR08 $15/90% SG $15/90% SG COBRA VALUE $15/90% SG COBRA 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 4/20/40 T2B H XGR8 4/20/40 T2B L XGR8 4/15/30 T2A H XGR8 4/15/30 T2A L XGR8 5/15/30 RX-GR08 15/35/50/50 X-GR08 NO RX 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 5/5 RX-GR08 383 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit 9WH 9WI 9WL 9WM 9XH 9XL 9YH 9YL 9ZH 9ZL A1C A1Z A3C A3Z AAB AAC AAF ABH ABL ACB ACD ACF AD2 AD9 ADA ADD ADF ADX AE2 AE3 AE4 AE5 AEF AF1 AF4 AF5 AF8 AFS AH1 AH2 AH3 AH4 AH5 AH6 AH7 AH8 AH9 AIC AIZ AJ1 Plan / Benefit Description 4/20/40 T1C H XGR8 15/25/40 I RX-GR08 4/20/40 T1C L XGR8 5/7.50 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 4/25/45 T3A H XGR8 4/25/45 T3A L ZGR8 94-AA-480 94-AA-480 COBRA AA-480 PREFERRED AA-480 PREFERRED COBRA UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK US BEHAVIORAL HEALTH NOT AVAIL CLK CNTY CODE SV 10/100% 07 SV 10/100% 07 CB ADMIN/CONSULTANTS FEE ADVANTAGE PLAN UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 10/100% 08 SV 10/100% 08 CB UNAVAIL USED IN WA CLARK 35/30V ACU/CHIRO/NAT/MASS 5/30V ACU/CHIRO/NAT/MASS 3/30V ACU/CHIRO/NAT/MASS 0/30V ACU/CHIRO/NAT/MASS EXECU-FIT BENEFIT SECURE HORIZONS B ONLY 20/12V ACU/CHIRO/NAT/MASS SECURE HORIZONS B ONLY SH LINN/BENTON/LANE B ONLY ADMINISTRATIVE SERVICE FEE $10/$1500 MAX CHIRO/ACU/NA $15/$2500 MAX/CHIRO/ACU/NA $10/30 CHIRO/ACU/NATU/MASS $15/30 CHIRO/ACU/NATU/MASS $20/30 CHIRO/ACU/NATU/MASS $25/30 CHIRO/ACU/NATU/MASS $0 /30 CHIRO/ACU/NATU/MASS $3 /30 CHIRO/ACU/NATU/MASS $5 /30 CHIRO/ACU/NATU/MASS DO NOT USE DO NOT USE SV 10/100% 384 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit AJ2 AJ3 AJ4 ALF ALH AM0 AMD AMF AMR AMZ APC APD APF APN APQ ART AS1 AS5 AS8 ASA ASB AT1 AT2 AT3 AT4 ATA ATB ATD ATF ATJ ATK ATP ATT ATU AW7 AW8 AWF AZ2 AZM AZT B2A B2B B2C B2D B2E B2F B2G B2H B2J B2P Plan / Benefit Description SV 10/100% CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV 20-40/300A AM MD 07 $35-30 VISITS CAM UNAVAIL USED IN CLARK WA AMMD RSP $20/$300 ADMT UNAVAIL USED IN CLARK WA AMER MED RESPONSE AMMD RSP $20/$300 ADMT CBR NOT AVAIL CLK CNTY CODE ALREADY USED 10/12V 1YR ACU SH07 10/12V 1YR ACU SH08 SP 10/100% AZUSA PAC 07 RESERVED ART SECURE HORIZONS STANDARD SECURE HORIZONS STANDARD SH LINN/BENTON/LANE ALLERGY SERUM-LOW PLAN ALLERGY SERUM - HIGH PLAN UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV $10-$15/$100A AT&T SV $10-$15/$100A AT&T CB SV 10-15/100A AT&T 06 UNAVAIL USED IN WA CLARK SV 10-15/100A AT&T 06 CB UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK ATW-PLUS SH-WL07 AT & T CORP ATW-PLUS WL-SH08 UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 20-40/300A AM MD 07 CB STANDARD 10 PLAN (COBRA) AMER MED RESPONSE COBRA AT & T CORP COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 385 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit B2R B3A B3B B3C B3D B3E B3F B3G B3H B3J B3P B3R B4A B4B B4C B4D B4E B4F B4G B4H B4J B4P B4R B4Z B5A B5B B5C B5D B5E B5F B5G B5H B5J B5P B5R B6A B6B B6C B6D B6E B6F B6G B6H B6J B6R B7A B7B B7C B7D B7E Plan / Benefit Description RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO BOEING $15/100% COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 386 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit B7F B7G B7H B7J B7P B7R B8A B8B B8C B8D B8E B8F B8G B8H B8J B8P B8R B9A B9B B9C B9D B9E B9F B9G B9H B9J B9P B9R BA1 BA2 BAA BAB BAC BAD BC1 BC8 BDB BDG BDM BEA BEB BEC BEG BEM BFM BGB BGM BH2 BH4 BH5 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO BASIC PLAN BASIC PLAN (2) UNAVAIL USED IN WA CLARK SV 15/100% BUP BOEIN 06 UNAVAIL USED IN WA CLARK SV 15/100% BUP BOEIN 06 CB BUBB-SH-LINN/BENTON ONLY USE SETTL&WHOLE STATE SV 10/100% BNA SLRD 07 SV 15-25/250A BOEING 07 SV 15/100% BNA HRLY 08 SV 10/100% BOEING 06 SV 10/100% BOEING 06 CB SV 10/100% BNA SLRD 08 SV 10/100% BNA SLRD 08 CB SV 15/100% BNA HRLY 08 CB SV 15-25/250A BOEING 08 SV 10/100% BNA SLRD 07 CB SV 15-25/250A BOEING 08 CB BOEING NA-HRLY $10 GRP RET BOEING HOURLY $15 GRP RET BASIC HEALTH PLAN SG 387 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit BH6 BJ1 BJ2 BJ3 BJ4 BJ5 BJ6 BJ7 BJ8 BK5 BK6 BKG BLA BLB BLP BMC BMJ BMP BNC BO1 BO4 BOE BOF BOG BOZ BP2 BP3 BP4 BP5 BP6 BP7 BP8 BP9 BPA BPC BPD BPE BPF BPG BPH BPJ BPK BPL BPM BPN BPP BPQ BPR BPS BPU Plan / Benefit Description BASIC HEALTH PLAN SG CBRA SV $10/80% SV $10/80% CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV $10/80% SG SV $10/80% SG CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE BASIC HEALTH PLAN BASIC HEALTH PLAN COBRA SV 15-25/250A BOEING 07 CB SV 10/100% BUP BOEIN 06 SV 10/100% BUP BOEIN 06 CB SV 10/100% BNA HRLY 08 SV 10/80% 07 SV 10/80% 07 CB SV 10/100% BNA HRLY 08 CB ****** OK TO USE THIS CODE BOEING $10/100% BOEING $15/100% SV $15-$25/$250A VEBA SV $15-$25/$250A VEBA CB UNAVAIL USED IN WA CLARK BOEING $10/100% COBRA RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVE PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 388 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit BPV BPW BPX BPY BPZ BR2 BR3 BR4 BR5 BR6 BR7 BR8 BR9 BRB BRC BRD BRJ BU1 BU2 BU3 BU4 BU5 BU6 BU7 BU8 BU9 BUC BUD BUE BUF BUG BUH BUI BUJ BUK BUL BUM BUN BVA BVB BVC BVD BVF BVK BVM BW7 BWA BWB BWC BWF Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO SV 15/100% BNA HRLY 07 UNAVAIL USED IN WA UNAVAIL USED IN WA UNAVAIL USED IN WA CLARK RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 15-25/250A BOEING 06 SV 15-25/250A BOEING 06 CB SV 10/80% 08 15/100A BOEING VEBA GR07 15 BO-VEBA NON-AARP GR08 UNAVAIL USED IN WA CLARK SV 10/100% BOEING 07 SV 15/100% BNA HRLY 07 CB SV 10/100% BOEING 07 CB SV 10/80% 08 CB 389 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit BX2 BX3 BX4 BX5 BX6 BX7 BX8 BX9 BXA BXB BXC BXD BXE BXF BXG BXH BXJ BXK BXL BXM BXN BXP BXR BXS BXT BXU BXV BXW BXX BXY BXZ BYA BYB BYC BYD BYE BYF BYG BYH BYJ BYK BYL BYM BYN BYP BYR BYS BZ1 BZ2 BZ3 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO BASIC PLAN (COBRA) BASIC PLAN (2) COBRA RESERVED RX PPO 390 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit BZ4 BZ5 BZ6 BZ7 BZ8 BZ9 BZA BZB BZC BZD BZE BZG BZH BZJ BZK BZL BZM BZN BZP BZR BZS BZT BZV BZW BZX BZY BZZ C1C C1Z C27 C2C C2K C2N C2Z C71 C72 C7A C7D C7E C7F C7G C7H C7J C7K C7L C7M C7P C7R C7S C7U Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 94-BA-480 94-BA-480 COBRA SC 90 ELIGIBILITY ONLY BA-480 STANDARD SV 15/250A CREDENCE 07 SV 15/250A CREDENCE 07 CB BA-480 STANDARD COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 5/12V 1YR GR-CH07 50%/$250MAX 1YR GR-CH07 10/12V 1YR GR-CH07 10/20V 1YR GR-CH07 10/30V 1YR GR-CH07 15/12V 1YR GR-CH07 15/20V 1YR GR-CH07 0/20V 1YR GR-CH07 15/30V 1YR GR-CH07 20/12V 1YR GR-CH07 5/10V 1YR GR-CH07 10/1500MAX GR-CH07 30/12V 1YR GR-CH07 5/20V 1YR GR-CH07 391 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit C7W C7Y C81 C82 C91 C92 CAA CAB CAD CAR CAV CAX CAY CBA CBB CBD CBF CBQ CCS CDA CDZ CE1 CE3 CE5 CE7 CEL CEO CF1 CF2 CF3 CFA CFD CFE CFF CFQ CG8 CG9 CGD CGF CGG CGI CGL CGO CGP CGS CGV CGX CH0 CH1 CHA Plan / Benefit Description 5/30V 1YR GR-CH07 5/40 1YR GR-CH07 NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 20/12V CH06 UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK CHIRO $20/20 VISITS 10/30V ACU/CHIRO/NAT/MASS 15/30V ACU/CHIRO/NAT/MASS 20/30V ACU/CHIRO/NAT/MASS SV 15/100A COMCAST 06 SV 15/80% SG07 SV 15/100A COMCAST 06 CB SV 15/80% SG07 CB 25/30V ACU/CHIRO/NAT/MASS OOA 5/1500D CHIRO 07 SV 15/250A C SCHWAB 06 SV 15/250A C SCHWAB 06 CB SECURE HORIZONS PLUS SH PLUS 3 LINN BENTON SH PLUS 5 LINN BENTON SH PLUS 7 LINN BENTON SV 10/250A 08 15/30V CH 07 SECURE HORIZONS B ONLY RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO SV 15-25/100A COMCST 07 10/20V CH 07 15/20V CH 07 SV 15/250A CSWB 07 SV 15/250A CSWB 07 CB CAREGIVER-SH GOLD CAREGIVER-SH INDIV CAREGIVER LITE SH06 CHIRO RET $10/$1500 MAX CAREGIVER PROGRAM CAREGIVER PROGRAM CAREGIVER CG-GR08 CAREGIVER ENHANCED CHIROPRACTIC CARE PEBB - CHIROCARE $10/20VISIT PEBB CHIRO1-99 392 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit CHB CHD CHE CHF CHG CHH CHI CHK CHO CHQ CHT CHU CHW CJ3 CJ4 CJ5 CJ6 CJ8 CL3 CL4 CL5 CL6 CMA CMC CMO CN4 CN6 CN7 CN8 CNC CNL CNZ CP5 CPA CPO CQ1 CR3 CR4 CR5 CR6 CRE CRG CRX CRY CS1 CS2 CS3 CS9 CSE CT1 Plan / Benefit Description CHIROCARE $35/30 VISITS CHIROCARE $10 CHIROCARE $15 CHIROCARE $20/30 VISITS CHIRO $25/30 VISITS CHIRO $0 /30 VISIT CHIRO $3 /30 VISITS CHIRO $10/40V CHIRO OUT-OF-AREA FED $15/30V ACU/CHIRO 2005 15/30V ACU/CH 06 10/12V 1YR SH-CH07 10/12V 1YR SH-CH08 NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV $15/80% BASIC PLAN SV $15/80% BASIC PLAN CB OOA ACU/CHIRO/NAT/MASS 07 20/30V CH 07 25/30V CH 07 NOT USED--SEE OLD CODE CHK FEDS 15/30V ACU/CHIRO 07 SV 10/250A 07 SV 10/250A 07 CB CAM OUT-OF-AREA 5/30V CH 07 35/30V CH 07 0/30V CH 07 3/30V CH 07 UWAA (CUSTOM 94-BA-480) SV 10/250A 08 CB UWAA-CUSTOM BA-480 (COBRA) $5G/$15BR RETIREE RESERVED PFFS PEBB CH RET 50%/$250MAX1YR 10/30V CH 07 GRP RET CHIRO $5/12VISITS GRP RET CHIRO $10/12VISITS GRP RET CHIRO $15/12VISITS GRP RET CHIRO $20/12VISITS SV 15/250A CREDENCE 08 CUSTOM PPO RESERVED FOR RX PPO RESERVED FOR RX PPO SH STANDARD - CORVALLIS C SCHWAB $15/100A C.SCHWAB $15/100 COBRA SV $15/$100A C SCHWAB CB SV $15/$100A C SCHWAB CHIROCARE $10/20 VISITS 393 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit CT2 CT3 CT4 CT5 CT6 CTE CTL CUC CUL CUZ CW7 CW8 CXK CXQ CZK D00 D05 D10 D1C D1P D1Y D1Z D20 D2C D2Z D50 D6V D8E D8M DBA DBO DC1 DC2 DC6 DCA DDA DDG DDP DDR DDS DFA DFC DFJ DIR DJ1 DJ2 DJ3 DJ4 DJP DJY Plan / Benefit Description CHIROCARE $15/20 VISITS CHIROCARE $15/30 VISITS CHIROCARE $5/30 VISITS CHIROCARE $10/30 VISITS 30/12V GR-CH07 SV 15/250A CREDENCE 08 CB SV 20/250A SCHWAB 08 94-BA-480 UNOCAL SV 20/250A SCHWAB 08 CB 94-BA-480 UNOCAL COBRA DO NOT USE DO NOT USE SV 15/80% SG 08 SV 15-25/100A COMCST 07 CB SV 15/80% SG 08 CB DURABLE MED EQUIP $0 DURABLE MED EQUIP 5%(SEBB) DME 10% 94-CA-480 94-CA-480 (OPTION) 94-CA-480 (OPTION) COBRA 94-CA-480 COBRA DME 20% CA-480 CA-480 COBRA DME 50% DENTAL - VISION GR06 $20 469 DN-SH08 $0 466 DN-SH08 100%/70% DISCOUNT GR-DN07 DNTL DISC PRGRM - OREGON PREMIER $5/100% PREMIER $5/100% COBRA $0 466 SH-DN06 SV 15/100% 08 SV 15/100% 08 CB DENTAL DISCOUNT RETIREES DENTAL DISCOUNT PROGRAM DENTAL DISCOUNT RETIREE DENTAL DISCOUNT PROGRAM SV 15/100% 07 FEDERAL EMPLOYEE PLAN SV 15/100% 07 CB DUMMY-USED FOR VRU CODING SV 10/250A SV 10/250A CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE JOSEPHINE COUNTY JOSEPHINE COUNTY (COBRA) 394 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit DK1 DK2 DK3 DK4 DM3 DM4 DN2 DN3 DNC DNP DNT DP1 DPO DPP DPY DQ6 DQP DQY DRC DT1 DTC DTO DTS DTZ DW7 DW8 DZ2 EA3 EA5 EAP ECE ECN ECP EE6 EE7 EE9 EEE EEN EEP EH6 EH7 EH9 EHA EHE EHJ EHN EHP EUC EVC EW7 Plan / Benefit Description PREMIER $5/100% PREMIER $5/100% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE DO NOT USE RESERVED PPO GRP RET DEN RESERVED PPO GRP RET DEN INACTIVE PLAN CODE-NOT USE INDEMNITY DENTAL DENTAL-ORIG. EFF 1/88 DEPENDENT LIFE BENE DOMESTIC PARTNERS COVERAGE POS-CA-480 POS-CA-480 COBRA $20 469 SH-DN06 CA-480 POS (IN-NETWK1&2) CA-480 POS(IN-NETWK1&2)CBR FEDERAL RETIRE PLAN 1994 DENTAL ONLY 94-CA-480 NATIONWIDE INDEMNITY DNTL ONLY (EOFF) PREV. DENTAL CHRN 3-12 94-CA-480 NATIONWIDE COBRA DO NOT USE DO NOT USE ADVANTAGE PLAN COBRA EAP-3 VISITS (PBHI) EAP-5 VISITS (PBHI) PBHI - EAP BENEFIT 10-20 NORTH C SH06 EPO 10-20 NORTH C SH06 10-20 NORTH C SH06 ODP MCC NO PP-PL SH07 MCC NO EP-PL SH07 MCC NO PLUS SH07 MCC NO EP SH07 MC COMP NO SH07 MCC NO PP SH07 MCC ESS NO PP-PL SH07 MCC ESS NO EP-PL SH07 MCC ESS NO PLUS SH07 SV 10-20/100A 07 MCC ESS NO EP SH07 SV 10-20/100A 07 CB MC COMP ESS NO SH07 MCC ESS NO PP SH07 SV 10-20/100A 08 SV 10-20/100A 08 CB DO NOT USE 395 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit EW8 F01 F02 F03 F04 F05 F06 F07 F08 F09 F10 F11 F12 F13 F14 F15 F16 F17 F18 F19 F1C F1M F1P F1X F1Y F1Z F20 F21 F22 F23 F24 F25 F26 F27 F28 F29 F2C F2Z F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 Plan / Benefit Description UNAVAIL USED IN WA CARK LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO $10G/$10B LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO 94-DA-480 94-DA-480 IPGB 94-DA-480 (OPTION) 94-DA-480 IPGB 94-DA-480 (OPTION) COBRA 94-DA-480 COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO DA-480 STANDARD 10 PLAN DA-480 STANDARD 10 PLAN CB LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO 396 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit F42 F43 F44 F45 F46 F47 F48 F49 F50 F51 F52 F53 F54 F55 F56 F57 F58 F59 F60 F9C F9Z FAA FAC FAD FAE FAH FAK FAL FAM FAZ FB2 FB3 FB6 FC1 FC2 FC5 FC6 FC8 FC9 FCA FCB FCE FCF FCI FCJ FCL FCM FCN FD4 FD5 Plan / Benefit Description LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDUEL PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO DA-480 SMALL GROUP DA-480 SMALL GROUP COBRA BOEING $10/100% EFF 1-00 SV 10-15/250A FIDLTY 06 UNAVAIL USED IN WA CLARK SV 10-15/250A FIDLTY 06 CB SV 25/240A FIDLTY 07 UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 25/240A FIDLTY 07 CB BOEING $10/100% EF 1-00CBR BOEING ERET 15/100 BOEING ERET 15/100 COBRA NOT AVAIL CLK CNTY CODE PREMIER $10/$100% PREMIER $10 100% COBRA PREMIER $10/100% SG PREMIER $10/100% SG COBRA RESERVED FOR RX PPO RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX FORD $20/100% SV $15-$45/$250D FEDS 397 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit FD6 FD7 FDA FDD FDE FDG FDZ FE1 FE2 FE3 FE4 FEC FEZ FF1 FF2 FFC FFF FFG FFS FFV FGC FH6 FHC FHD FHG FHJ FHR FI3 FI4 FID FJD FK1 FK2 FK3 FK4 FK5 FK6 FK7 FK8 FM6 FMC FMM FMN FMV FMW FMX FMZ FN1 FN2 FNA Plan / Benefit Description SV 20/100% FORD 05 SV 20/100% FORD 05 CB UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 35/240A FID IN SV 06 SV 35/240A FID IN SV 06 CB FORD $20/100% COBRA FEDERAL EMPLOYEES FEDERAL EMPLOYEES (2) FEDERAL EMPLOYEES 1991 FEDERAL EMPLOYEES 1993 STANDARD 10 PLAN STANDARD 10 PLAN COBRA FIREMAN FUND FIREMAN FUND COBRA FEDERAL EMPLOYEE PLAN FEH ADMINISTRATIVE RETENTION SV 35/240A FIDELITY 07 FITNESS SH/GR-WL07 FITNESS SH/GR-WL08 FEDERAL EMPLOYEES PLAN1-99 SV 15-30/200D FEDS 06 FEDS 2001 FEDS 2003 SV 35/240A FIDELITY 07 CB SV 15-30/250A 07 SV 15-30/250A 07 CB DO NOT USE NOT AVAIL CLK CNTY CODE FEDS INDEMNITY DENTAL 2001 FEDS 2004 PREMIER $10/100% PREMIER $10/100% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE PREMIER $10/100% SG PREMIER $10/100% SG COBRA DO NOT USE CLK CNTY CODE DO NOT USE CLK CNTY CODE SV 20/100% FORD 06 CB SV 20/100% FORD 06 NOT AVAILABLE SV $15-30/250A FARMERS SV 20/100% FORD 07 SV 15-30/250A 08 SV 20/100% FORD 07 CB NOT AVAILABLE FIDELITY NATL FINANCIAL FIDELITY NAT FINANCE COBRA UNAVAIL USED IN WA CLARK 398 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit FND FNE FNZ FP1 FP2 FPA FPB FPC FPD FPP FPY FQP FQY FR1 FR2 FR3 FR4 FRA FRM FRS FW7 FWW FZM G1C G1P G1Y G1Z G2C G2Z GC1 GC2 GC3 GC4 GCB GCJ GJ1 GJ2 GLB GLC GRC GW7 GZ2 H01 H02 H03 H04 H05 H06 H07 H08 Plan / Benefit Description SV 10-15/250A FIDELITY SV 10-15/250A FIDELITY CB SV $15-30/250A FARMERS CB POS $10/100%/75% POS $10/100%/75% COBRA POS $10/100%/75% POS $10/100%/75% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE POS-DA-480 POS-DA-480 COBRA DA-480 POS(IN-NETWK3&4) DA-480 POS(IN-NETWK3&4)CBR FEDERAL RETIREES PLAN FEDERAL RETIREES PLAN (2) FEDERAL EMPL. RETIREES FEDERAL EMP. RETIREES 1993 RISK CHARGE - AGGREGATE FARMERS INS RISK CHARGE - SPECIFIC UNAVAIL USED IN WA CLARK SV 15-30/250A 08 CB FARMERS INS COBRA 94-EA-480 94-EA-480 (OPTION) 94-EA-480 (OPTION) COBRA 94-EA-480 COBRA EA-480 EA-480 COBRA CORVALLIS $20/$500 CORVALLIS $20/$500 COBRA CORVALIS CLINIC $20/90% COR CLINIC $20/90% COBRA SV 20-40/400A 07 SV 20-40/400A 07 CB SV 15/100% SV 15/100% CB SV 20-40/400A 08 SV 20-40/400A 08 CB DUMMY DO NOT USE THE BASIC HEALTH PLAN CBR DOMESTIC PARTNERSHIP PPO VISION CARE BENEFIT PPO FAMILY PLANING BENEFIT PPO 24/HOUR HEALTH INFO PPO HEARING AID BENEFIT PPO MENTAL NON-SMI PPO 90/70 RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT 399 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit H09 H10 H11 H12 H13 H14 H15 H16 H17 H18 H19 H1Z H20 H21 H22 H23 H24 H25 H26 H27 H28 H29 H2Z H30 H31 H32 H33 H34 H35 H36 H37 H38 H39 H3Z H40 H41 H42 H43 H44 H45 H46 H47 H48 H49 H50 H51 H52 H53 H54 H55 Plan / Benefit Description MENTAL NON-SMI 80/60 MENTAL NON-SMI PPO 80/50 MENTAL NONSMI INDEMNITY 80 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO PREFERRED $10/$20/$100 CBR RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO PREFERRED $15/$30/$250 CBR RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 20-40/400A COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 400 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit H56 H57 H58 H59 H60 H61 H62 H63 H64 H65 H66 H67 H68 H69 H6P H70 H71 H72 H73 H74 H75 H76 H77 H78 H79 H80 H81 H82 H83 H84 H85 H86 H87 H88 H89 H8A H90 H91 H92 H93 H94 H95 H96 H97 H98 H99 HA1 HA2 HAJ HAN Plan / Benefit Description RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 15-25/100A GR06 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 0/500A 3YRS PL HA-SH08 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO HEARING AIDS SEBB $500 HEARING AID PEBB1-99 HEARING AID $500 EVERY 3YR 300A/24M GR-HA07 401 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit HAO HB1 HB2 HB3 HCE HCN HCP HDC HDE HDN HEP HEQ HFC HFQ HFR HG1 HG2 HG3 HG4 HG6 HG7 HG9 HGC HGE HGI HGN HGO HGP HGQ HGU HGV HGW HGY HHE HIH HIZ HJ1 HJ2 HJ3 HJ4 HJ6 HJ7 HJ9 HJE HJN HJP HK1 HK2 HK3 HK4 Plan / Benefit Description HEARING AID BENEFIT RESERVED FPR PPO PRODUCT RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT 15-30 SOUTH C SH06 EPO 15-30 SOUTH C SH06 15-30 SOUTH C SH06 ODP SV 15/300D 07 300A 2YRS HA-GR08 SV 15/300D 07 CB UNAVAILABLE IN WA CLARK UNAVAILABLE IN WA CLARK SV 15/300D 08 SV 20-40/500A HP 07 SV 20-40/500A HP 07 CB SV 10-20/100A SV 10-20/100A CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE MCC SO PP-PL SH07 MCC SO EP-PL SH07 MCC SO PLUS SH07 SV 15/300D 08 CB MCC SO EP SH07 ARP MCC SO EP-PL SH08 MC COMP SO SH07 HRING AID RET $1000/MAX3YR MCC SO PP SH07 ARP MCC SO PP-PL SH08 ARP MCC SO PP SH08 ARP MCC SO PLUS SH08 ARP MCC SO SH08 ARP MCC SO EP SH08 500A 3YRS HA-GR08 HINES HORT $20/$300D HINES HORT $20/$300D COBRA SV 15-30/250A SV 15-30/250A CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE MCC ESS SO PP-PL SH07 MCC ESS SO EP-PL SH07 MCC ESS SO PLUS SH07 MCC ESS SO EP SH07 MC COMP ESS SO SH07 MCC ESS SO PP SH07 SV 20-40/400A SV 20-40/400A CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 402 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit HM1 HM2 HM3 HME HMN HMP HOA HOE HOI HP1 HP2 HP3 HPA HPB HPC HPD HPE HPF HPH HPJ HPN HPO HPS HPZ HQC HR2 HR3 HRP HSH HTC HTH HW7 HZ2 I01 I02 I03 I04 I05 I06 I07 I0V I1C I1P I1Y I1Z I24 I2C I2Z I81 I82 Plan / Benefit Description PREFERRED $10/$20/$100 PREFERRED $15/$30/$250 20-40/400A 15-30 SOUTH M SH06 EPO 15-30 SOUTH M SH06 15-30 SOUTH M SH06 ODP RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED HEARING PFFS HP $15/$300A 550 PLAN HP $15/$300A COBRA SV $15-$30/$500A HP SV $15-$30/$500A HP CB UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK RESERVED PFFS SV 15-30/500A HP 06 20-40/500A HP GR07 UNAVAIL USED IN WA CLARK 20-40/500A HP NO-AARP GR08 PEBB HRING AID $300MAX3YRS UNAVAIL USED IN WA CLARK SV 15-30/500A HP 06 CB $300 MAX 3YRS PEBB HA-GR08 HRING AID $500 ALLOWANCE HRING AID $300 ALLOWANCE 0/500A 3YRS PL SH-HA07 SV 20-40/90% HP 08 500A 2YRS HA-GR08 SV 20-40/90% HP 08 CB UNAVAIL USED IN WA CLARK 550 PLAN COBRA INDEMNITY COVERAGE PLAN EOFF ELECTRIC INDEMNITY INDEMNITY PPO INDEMNITY OOA (DEPENDENT) INDEMNITY OOA (SUBS) OOA SUBSCRIBER PLAN I OOA SUBSCRIBER PLAN II VISION PLAN /STAND ALONE 94-CB-800 94-CB-800 OPTION 94-CB-800 OPTION COBRA 94-CB-800 COBRA INPUT ERROR CB-800 VALUE PLAN CB-800 VALUE PLAN COBRA IND. CONV. PLAN -880 IND. CONV. PLAN -880 (2) 403 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit IC2 ICI ICP IGJ IGL IOA IOC IPI IS1 IZ1 IZ2 IZ3 IZ4 IZ5 IZ6 IZ7 IZA IZC IZV JAA JAJ JCA JCB JJ1 JJ2 JJA JJB JJF JJN JJY JJZ JKG JLG JW7 K1C K1P K1Y K1Z K2C K2P K2Y K2Z K3P K3Y K4C K4Z K5C K5Z K9C K9P Plan / Benefit Description INDIVIDUAL CONVERSION 7/90 SV 15-30/100% ICI PNTS SV 15-30/100% ICI PNTS CB UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK INDEMNITY OUT-OF-AREA INDEMNITY SG OUT-OF-AREA UNAVAIL USED IN WA CLARK IND. CONV. PLAN - SHARE INDEMNITY PLAN COBRA EOFF ELECTRIC INDEMNITY CB INDEMNITY PPO INDEMNITY OOA (DEPENDENT) INDEMNITY OOA (SUBS) COBRA OOA SUBSCRIBER PLAN I COBR OOA SUBSCRIBER PLAN II CBR INDEMNITY OUT-OF-AREA CBRA INDEMNITY SG OOA COBRA VISION PLAN / STAND ALONE SV 15-35/250A J&J-NE 06 SV 15-35/250A J&J-NE 06 CB SV 15/70% 08 SV 15/70% 08 CB SV 15/300D SV 15/300D CB SV 15/70% 07 SV 15-35/250A J&J 06 SV 15-35/250A J&J 06 CB SV JOHN&JOHN 15-35/250A SV 15/70% 07 CB SV JOHN&JOHN 15-35/250A CB SV 15-35/250A J&J 08 SV 15-35/250A J&J 08 CB UNAVAIL USED IN WA CLARK 94-DB-1000 SHARE PLAN 10-20 POS SHARE PLAN 10-20 COBRA POS 94-DB-1000 COBRA DB-1000 IPGB 94-DB-1000-OPTION 94-DB-1000-OPTION COBRA DB-1000 IPGB COBRA DB-1000 POS ORE-MET UNION DB-1000-POS ORE MET COBRA DB-1000 SHARE PLAN DB-1000 SHARE PLAN COBRA 00-DB-1000 00-DB-1000 COBRA DB-1000 20% PLAN SMALL GRP DB-1000 POS SMALL GROUP 404 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit K9Y K9Z KA2 KA3 KA4 KA5 KA6 KA7 KA8 KA9 KAC KAP KAY KAZ KB2 KB3 KB4 KB5 KB6 KB7 KB8 KB9 KBB KBJ KC1 KC2 KC5 KC6 KCG KD2 KD3 KD4 KD5 KD6 KD7 KD8 KD9 KE2 KE3 KE4 KE5 KE6 KE7 KE8 KE9 KF2 KF3 KF4 KF5 KF6 Plan / Benefit Description DB-1000 POS SMALL GROUP CB DB-1000 20% SMALL GRP COBR RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 00-DB 1000 SMALL GROUP 00-DB 1000 POS SMALL GRP 00-DB 1000 POS SMALL COBRA 00-DB 1000 SMALL GRP COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20/500D 07 SV 20/500D 07 CB PREMIER $10/80% PREMIER $10/80% COBRA PREMIER $10/80% SG PREMIER $10/80% SG COBRA SV 5/100% KRAFT FDS 07 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 405 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit KF7 KF8 KF9 KFA KFB KFC KFD KG2 KG3 KG4 KG5 KG6 KG7 KG8 KG9 KH8 KH9 KJ2 KJ3 KJ4 KJ5 KJ6 KJ7 KJ8 KJ9 KK1 KK2 KK3 KK4 KK5 KK6 KK7 KK8 KKA KL2 KL3 KL4 KL5 KL6 KL7 KL8 KL9 KM2 KM3 KM4 KM5 KM6 KM7 KM8 KM9 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO SV 5/100% KRAFT FDS 06 SV 5/100% KRAFT FDS 06 CB SV 3/100% KRAFT FDS 06 SV 3/100% KRAFT FDS 06 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PREMIER $10/80% PREMIER $10/80% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE PREMIER $10/80% SG PREMIER $10/80% SG COBRA DO NOT USE CLK CNTY CODE DO NOT USE CLK CNTY CODE UNAVAIL USED IN WA CLARK RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 406 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit KMA KMG KNA KP1 KP2 KPC KPD KPP KPY KQ1 KQ2 KQA KQB KQC KQD KQP KQY KR2 KR3 KR4 KR5 KR6 KR7 KR8 KR9 KRF KRP KRY KS2 KS3 KS4 KS5 KS6 KS7 KS8 KS9 KT2 KT3 KT4 KT5 KT6 KT7 KT8 KT9 KU2 KU3 KU4 KU5 KU6 KU7 Plan / Benefit Description SV 5/100% KRAFT FDS 08 SV 5/100% KRAFT FDS 07 CB SV 5/100% KRAFT FDS 08 CB POS $10/100%/60% POS $10/100%/60% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE POS-DB-1000 POS-DB-1000 COBRA POS $10/80%/60% POS $10/80%/60% COBRA POS $10/80%/60% POS $10/80%/60% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE DB-1000 POS(IN-NETWK5) DB-1000 POS (IN-NETWK5)CBR RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 3/100% KRAFT 07 00-DB 1000 POS(IN-NETWK5) 00-DB 1000POS(IN-NETWK5)CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 407 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit KU8 KU9 KUH KV2 KV3 KV4 KV5 KV6 KV7 KV8 KV9 KVH KW2 KW3 KW4 KW5 KW6 KW7 KW8 KW9 KWA KWH KX2 KX3 KX4 KX5 KX6 KX7 KX8 KX9 KXF KY2 KY3 KY4 KY5 KY6 KY7 KY8 KY9 L01 L02 L03 L04 L05 L06 L07 L08 L09 L1I LCG Plan / Benefit Description RESERVED PPO RESERVED PPO SV 20/500D 08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20/500D 08 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 3/100% KRAFT FDS 08 SV 3/100% KRAFT FDS 08 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 3/100% KRAFT 07 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO LIFE W/SEATBELT (LARGE) LIFE W/SEATBELT (LARGE) LIFE PLAN - SMALL GROUP LIFE PLAN - SMALL GROUP LIFE PLAN - SG INTERNET LIFE PLAN - SG INTERNET LIFE PLAN - LARGE GROUP LIFE PLAN - LARGE GROUP LIFE PLAN - LARGE GROUP 94-FB-1200 SV 20/250A 08 408 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit LDA LDB LDG LEA LEJ LF1 LL3 LO6 LO7 LOW LOZ LPA LPB LPC LPD LPE LPF LTD LTM LW7 LW8 M03 M10 MA1 MA2 MA3 MA4 MA5 MA6 MA7 MA8 MBA MBH MBZ MDA MDC MDJ MF5 MF8 MFF MGA MH0 MHK MHO MJ1 MJ2 MJ5 MJ6 MJ7 MJ8 Plan / Benefit Description SV 20/85% LOWE'S 06 SV 20/85% LOWE'S 06 CB SV 20/250A 08 CB SV 20/250A 07 SV 20/250A 07 CB LIFE W/SEATBELT (SMALL) LIFELINK- MEN. AND CHEM SV LOWES $20/85% SV LOWES $20/85% CB $20/85% LOWES $20/85% LOWES COBRA POS $20/80%/60% POS $20/80%/60% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE POS $20/80%/60% SG POS $20/80%/60% SG COBRA RESERVED FOR PPO LIFE $2MILLION LIFETIME MAXIMUM UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK MEDICAID $10 MAN GEN OHP - MEDICAL COVERAGE OHP-MEDI-CAL PART B ONLY 0HP - 133 FPL CHILD OHP - GENERAL ASSIST OHP-100 FPL (MENTAL ONLY) OHP-FPL ADULT MENTAL ONLY OHP-FPL CHILD MENTAL ONLY OHP-GEN. ASST. MENTAL ONLY MULTNOMAH BAR ASSOC SV 20-30/90% MCKSON 07 MULTNOMAH BAR ASSOC COBRA SV 10/200D 07 MEDICAID PLAN SV 10/200D 07 CB SECURE HORIZONS B ONLY SH JACKSON B ONLY SV 10/200D 08 ENTERED IN ERROR OK TO USE OHP - MENTAL HEALTH ONLY 30/200D FEDS MH06 USE ONLY FOR ALL STATE MH SV $15/70% SV $15/70% CB SV $15/70% SG SV $15/70% SG CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 409 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit MJF MK5 MK6 MKY MKZ MM1 MM2 MMF MR1 MS1 MS5 MS8 MTK MTM MW6 MW7 MZ1 N01 N02 N03 N04 N05 N06 N07 N08 N09 N0H N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N1B N1H N1I N1N N1Z N20 N21 N22 N23 N24 N25 N26 N27 Plan / Benefit Description SV 10/200D 08 CB SV 20-30/90 MCKESSON SV 20-30/90% MCKSN 06 SV 20-30/90% MCKSN 06 CB SV 20-30/90 MCKESSON CB SECURE HORIZONS OHP SECURE HORIZONS OHP B ONLY SV 20-30/90% MCKSON 07 CB MARRIOTT PLAN $10 MAN GEN SECURE HORIZONS STANDARD SH JACKSON 10/5V 1YR MSG THRPY SH07 10/5V 1YR MSG THRPY SH08 UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK MARRIOTT PLAN COBRA INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS NOT AVAIL CLK CNTY CODE INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS NAT $10/$100 MH BUYUP CBRA NATL $10/$20/$100 COBRA NATL$10/$20/$100W/BUYUP CO SV 5/100% NAT'L 06 CB NATL PLAN $10/100 COBRA INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS 410 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit N28 N29 N2B N2H N2I N2J N2N N2Z N30 N3B N3H N3I N3J N3N N3Z N4B N4H N4I N4J N4N N4Z N5B N5H N5I N5J N5N N5Z N6H N6J N6N N7H N7J N7N N8H N8J N8N N9H N9J N9N NA1 NA2 NA3 NA4 NA5 NA6 NA8 NAA NAB NAC NAD Plan / Benefit Description INDEMNITY PLANS INDEMNITY PLANS NAT $15/$250 MH BUYUP CBRA NATL $15/$30/$250 COBRA NATL$15/$30/$250W/BUYUP CO SV 5/100% NATL 07 AB SV 10/100% NAT'L 06 CB NATL PLAN $15/$250 COBRA INDEMNITY PLANS NAT $15/$400 MH BUYUP CBRA NATL $15/$30/$400 COBRA NATL$15/$30/$400W/BUYUP CO SV 10/100% NATL 07 CB SV 15/100% NAT'L 06 CB NATL PLAN $15/$400 COBRA NAT $20/$250 MH BUYUP CBRA NATL $20/$40/$250 COBRA NATL$20/$40/$250W/BUYUP CO SV 15/100% NATL 07 CB SV 10-20/100A NATL 06 CB NATL PLAN $20/$250 COBRA NAT $20/$400 MH BUYUP CBRA NATL $20/$40/$400 COBRA NATL$20/$40/$400WBUYUP COB SV 10/100A NATL 07 CB SV 15-30/250A NATL 06 CB NATL PLAN $20/$400 COBRA NOT AVAIL CLK CNTY CODE SV 10/250A NATL 07 CB SV 15-30/400A NATL 06 CB NOT AVAIL CLK CNTY CODE SV 15/250A NATL 07 CB SV 20-40/250D NATL 06 CB NOT AVAIL CLK CNTY CODE SV 15/100A NATL 07 CB SV 10/250A NATL 06 CB NOT AVAIL CLK CNTY CODE SV 35/500D NATL 07 CB SV 15/250A NATL 06 CB PHS NATL $5/100% CBRA PHS NATL $10/100% CBRA PHS NATL $10/$100/100%CBRA PHS NATL $10/$250/100%CBRA PHS NATL $15/$250/100%CBRA PHS NAT'L $15/100% COBRA PHS NATL $15/$100/100% CBR PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100/100% PHS NATL $10/$250/100% 411 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit NAE NAF NAG NAH NAI NAJ NAK NAL NB0 NB1 NB2 NB3 NB4 NB5 NB6 NB7 NB8 NB9 NBA NBB NBC NBD NBE NBF NBG NBH NBJ NBK NBL NBM NBN NBP NBQ NBR NC1 NC2 NC3 NC4 NC5 NC6 NC7 NCA NCJ NCK NCL ND1 ND2 ND3 ND4 ND5 Plan / Benefit Description PHS NATL $15/$250/100% PHS NAT'L $15/100% NATL POS $10/100%/70% NATL POS $10/90%/70% PHS NATL $15/$100/100% NATL POS $10/$250/100% NATL POS $15/80%/60% NATL POS $15/$150/70% NOT AVAIL CLK CNTY CODE NAT $10/$100 MH BUYUP NAT $15/$250 MH BUYUP NAT $15/$400 MH BUYUP NAT $20/$250 MH BUYUP NAT $20/$400 MH BUYUP NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE UNAVAIL USED IN WA CLARK UNAVAIL USED IN CA CLARK UNAVAIL USED IN WA CLARK SV 5/100% NATL 07 UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVIAL USED IN WA CLARK UNAVAIL USED IN WA CLARK $15/$250/WSUPP RITE AIDCBR DO NOT USE C COUNTY CODE DON'T USE CLK COUNTY CODE DON'T USE CLK COUNTY CODE DON'T USE CLK COUNTY CODE DON'T USE CLK COUNTY CODE DON'T USE CLK COUNTY CODE $15/$250/WSUPP RITE AID SV 10/100% NATL 07 SV 10-20/100A NATL 08 SV 5/100% NATL 08 NATL POS $10/100%/70% CBRA NATL POS $15/$150/70% CBRA NATL POS $10/90%/70% COBRA NATL POS $10/$250/60% CBRA NATL POS $15/80%/60% COBRA 412 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit NDA NDB NDC NDD NDE NDF NDG NDJ NDK NDL NE1 NE2 NE3 NE4 NE5 NE6 NE7 NE8 NEA NEB NEC NED NEE NEF NEG NEH NEJ NEK NEL NEP NEY NF4 NF5 NF6 NF7 NF8 NFD NFE NFF NFG NFH NFJ NFK NFL NFM NFN NFP NFQ NFR NFS Plan / Benefit Description NATL POS $10/100%/70% NATL POS $15/$150/70% NATL POS $10/90%/70% NATL POS $10/$250/60% NATL POS $15/80%/60% SV 10-20/100A NATL 07 SV 10-20/100A NATL 07 CB SV 15/100% NATL 07 SV 10-20/100A NATL 08 CB SV 5/100% NATL 08 CB NATL $5/100% COBRA NATL $10/100% COBRA NATL $15/100% COBRA NATL $10/$100/100% COBRA NATL $10/$250/100% COBRA NATL $15/$250/100% COBRA NATL $15/$100/100% COBRA NATL $35/$500D COBRA NATL $5/100% NATL $10/100% NATL $15/100% NATL $10/$100/100% NATL $10/$250/100% NATL $15/$250/100% NATL $15/$100/100% NATL $35/$500D SV 10/100A NATL 07 SV 15-30/250A NATL 08 SV 10/100% NATL 08 NEC AMERICA CUSTOM POS NEC AMERICA CUSTOM POS CBR SV 10-20/100A NATL CB SV 15-30/250A NATL CB SV 15-30/400A NATL CB SV 20-40/250D NATL CB SV 20-40/400D NATL CB SV 10-20/100A NATL SV 15-30/250A NATL SV 15-30/400A NATL SV 20-40/250D NATL SV 20-40/400D NATL SV 10/250A NATL 07 SV 15-30/250A NATL 07 SV 15-30/250A NATL 07 CB SV 15-30/400A NATL 07 SV 20-40/250D NATL 07 SV 15-30/400A NATL 07 CB SV 20-40/250D NATL 07 CB SV 20-40/400D NATL 07 SV 20-40/400D NATL 07 CB 413 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit NGA NGC NGJ NGK NGL NGZ NH0 NH1 NH2 NH3 NH4 NH5 NH6 NH7 NH8 NH9 NHG NHJ NHK NHL NHZ NI1 NI2 NI3 NI4 NI5 NJ1 NJ2 NJ3 NJ4 NJ5 NJ6 NJ7 NJ8 NJ9 NJA NJB NJC NJD NJE NJF NJG NJH NJJ NJK NJL NJM NJN NJP NJQ Plan / Benefit Description NAT'L PLN 2C $20 GRP RET NAT'L PLN 2D $20 GRP RET SV 15/250A NATL 07 SV 15-30/250A NATL 08 CB SV 10/100% NATL 08 CB NATL POS $10/100%/70% CBRA NOT AVAIL CLK CNTY CODE NATL $10/$20/$100 NATL $15/$30/$250 NATL $15/$30/$400 NATL $20/$40/$250 NATL $20/$40/$400 NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV 15/100% NATL 08 SV 15/100A NATL 07 SV 15-30/400A NATL 08 SV 15/100% NATL 08 CB NATL POS $10/90%/70% COBRA NATL $10/$20/$100 W/ BUYUP NATL $15/$30/$250 W/BUYUP NATL $15/$30/$400 W BUY UP NATL $20/$40/$250 W/BUYUP NATL $20/$40/$400 W BUY UP NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE UNAVAIL USED IN WA CLARK NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK 414 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit NJR NJS NJT NJU NJV NJW NJX NJY NJZ NK1 NK2 NK3 NK4 NK5 NK6 NK7 NKA NKB NKC NKD NKE NKF NKG NKJ NKK NKL NKZ NL1 NL2 NL3 NL4 NL5 NL8 NLA NLB NLC NLD NLE NLK NLL NLZ NM1 NM2 NM3 NM4 NM5 NN1 NN2 NN3 NN4 Plan / Benefit Description UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK NATL POS $10/$250/100% CBR NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV 35/500D NATL 07 SV 15-30/400A NATL 08 CB SV 10/100A NATL 08 NATL POS $15/80%/60% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 24HR NURSLINE WL-SH/GR08 NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV 20-40/250D NATL 08 SV 10/100A NATL 08 CB NATL POS $15/$150/70% CBRA NATL PLAN $10/$100 NATL PLAN $15/$250 NATL PLAN $15/$400 NATL PLAN $20/$250 NATL PLAN $20/$400 SV 5/100% NATL CB SV 10/100% NATL CB SV 15/100% NATL CB SV 10/100A NATL CB 415 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit NN5 NN6 NN7 NN8 NNA NNB NNC NND NNE NNF NNG NNH NNK NNL NNM NNN NNP NNQ NNR NNS NNT NNU NNV NNW NNY NO1 NO2 NO3 NO4 NO5 NO6 NO7 NP1 NP2 NP3 NP4 NP5 NP6 NP8 NPA NPB NPC NPD NPE NPF NPI NQ1 NQ2 NQ3 NQ4 Plan / Benefit Description SV 10/250A NATL CB SV 15/250A NATL CB SV 15/100A NATL CB SV 35/500D NATL CB SV 5/100% NATL SV 10/100% NATL SV 15/100% NATL SV 10/100A NATL SV 10/250A NATL SV 15/250A NATL SV 15/100A NATL SV 35/500D NATL SV 10/250A NATL 06 SV 15/100A NATL 06 SV 10/100% NAT'L 06 SV 5/100% NAT'L 06 SV 15/250A NATL 06 SV 10-20/100A NATL 06 SV 10/100A NAT'L 06 SV 15-30/400A NATL 06 SV 20-40/250D NATL 06 SV 15/100% NAT'L 06 SV 15-30/250A NATL 06 SV 35/500D NATL 06 SV 20-40/400D NAT'L06 NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 2B $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET PHS NATL $5/100%W/SUPP CBR PHS NATL $10/100%W/SUPPCBR PHS NATL$10/$100/WSUPP CBR PHS NATL$10/$250/100SUPPCB PHS NATL$15/$250/100SUPPCB PHS NATL $15/100%W/SUPPCBR PHS NATL15/$100/100WSUPCBR PHS NATL $5/100% W/SUPP PHS NATL $10/100%W/SUPP PHS NATL$10/$100/100%WSUPP PHS NATL$10/$250/100WSUPP PHS NATL$15/$250/100WSUPP PHS NATL $15/100%W/SUPP PHS NATL $15/$100/100WSUPP SV 5/100% NATL BU CB SV 10/100% NATL BU CB SV 15/100% NATL BU CB SV 10/100A NATL BU CB 416 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit NQ5 NQ6 NQ7 NQ8 NQ9 NQA NQB NQC NQD NQE NQF NQG NQH NQJ NQK NQL NQM NQN NQP NQQ NQR NQS NQT NQU NQV NQW NQX NQY NQZ NS1 NS2 NS3 NS4 NS5 NS6 NS7 NS8 NSA NSB NSC NSD NSE NSF NSG NSH NTK NTL NTN NU1 NU2 Plan / Benefit Description SV 10/250A BH NATL CB SV 15/250A NATL BU CB SV 15/100A NATL BU CB SV 35/500D NATL BU CB SV 35/500D B-UP NATL 06 SV 5/100% NATL BU SV 10/100% NATL BU SV 15/100% NATL BU SV 10/100A NATL BU SV 10/250A BH NATL SV 15/250A NATL BU SV 15/100A NATL BU SV 35/500D NATL BU SV 5/100% NATL BU06 SV 5/100% NATL BU06 CB SV 10/100% NATL BU06 SV 10/100% NATL BU06 CB SV 10/100A NAT'L 06 CB SV 15/100% NATL BU06 SV 15/100% NATL BU06 CB SV 10/100A NATL BU06 SV 10/100A NATL BU06 CB SV 10/250A B-UP NATL 06 SV 10/250A B-UP NATL 06 CB SV 15/250A B-UP NATL 06 SV 15/250A B-UP NATL 06 CB SV 15/100A B-UP NATL 06 SV 15/100A B-UP NATL 06 CB SV 35/500D B-UP NATL 06 CB NATL $5/100% W/BUYUP COBRA NATL $10/100%W/BUYUP COBRA NATL $15/100% W BYUP COBRA NAT $10/$100/100% BYUP CBR NATL$10/$250/100%WBUYUP CO NAT $15/$250/100% BYUP CBR NAT $15/$100/100% BYUP CBR NATL $35/$500D BUYUP CBRA NATL $5/100% W/ BUY UP NATL $10/100% WITH BUY-UP NATL $15/100% W BUYUP NATL $10/$100/100% BUYUP NATL $10/$250/100% W BUYUP NATL $15/$250/100% BUYUP NATL $15/$100/100% BUYUP NATL $35/$500D BUYUP SV 20-40/250D NATL 08 CB SV 10/250A NATL 08 SV 15/100A NATL 06 CB SV 10-20/100A NATL BU CB SV 15-30/250A NATL BU CB 417 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit NU3 NU4 NU5 NUA NUB NUC NUD NUE NUF NUG NUH NUK NUL NUM NUN NUP NUQ NUR NWG NWI NWL NWN NWZ NXK NXL NYK NYL NYN NZC NZG NZK NZL O1U O1V O1X O22 O2H O2U O2V O2X O3U O3V O3X O4U O4V O4X O5U O5V O5X O6U Plan / Benefit Description SV 15-30/400A NATL BU CB SV 20-40/250D NATL BU CB SV 20-40/4OOD NATL BU CB SV 10-20/100A NATL BU SV 15-30/250A NATL BU SV 15-30/400A NATL BU SV 20-40/250D NATL BU SV 20-40/4OOD NATL BU SV 10-20/100A NATL BU06 SV 10-20/100A NATL BU06 CB SV 15-30/250A NATL BU06 SV 15-30/250A NATL BU06 CB SV 15-30/400A NATL BU06 SV 15-30/400A NATL BU06 CB SV 20-40/250D NAT BU 06 SV 20-40/250D NAT BU 06 CB SV 20-40/400D NAT BU 06 SV 20-40/400D NAT BU 06 CB UNAVAIL USED IN WA CLARK SV $15-30/250D NATIONWD SV 10/250A NATL 08 CB SV 35/500D NATL 06 CB SV $15-30/250D NATIONWD CB SV 35/500D NATL 08 SV 15/100A NATL 08 SV 35/500D NATL 08 CB SV 15/100A NATL 08 CB SV 20-40/400D NAT'L06 CB SV 15/250A NATL 08 SV 15/250A NATL 08 CB SV 20-40/400D NATL 08 SV 20-40/400D NATL 08 CB 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 NAT'L PLN 2 $10 GRP RET BOEING NA-HRLY $10 GRP RET 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 15-30/220D T3B GR07 418 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit O6V O6X O70 O71 O72 O7U O7V O7X O7Z O80 O81 O82 O8U O8V O8X O8Z O90 O91 O92 O9U O9V O9X O9Z OA1 OA2 OA4 OAN OAV OB1 OB2 OB4 OBH OBP OCU OCY OD1 OD2 OD4 OE1 OE2 OE4 OF1 OF2 OF3 OF4 OF5 OF6 OF7 OF8 OF9 Plan / Benefit Description 15-25/130D T2B GR07 5-20/100A T1B GR07 VALUE $25/70% $25/70% $25/70% COBRA 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 VALUE $25/70% COBRA VALUE $20/80% $20/80% $20/80% COBRA 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 VALUE $20/80% COBRA VALUE $15/90% $15/90% $15/90% COBRA 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 VALUE $15/90% COBRA NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 NATIONAL ACCT EXTENDED OOA OUT OF AREA VISION NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 BOEING HOURLY $15 GRP RET 15 BO HRLY-F NO-AARP GR08 OSU POS $10/100%/75% OSU POS $10/100%/75% COBRA NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO 419 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit OFA OFB OFC OFD OFE OG1 OG2 OG4 OH1 OH2 OH3 OH4 OH7 OH8 OHP OIT OJ2 OJO OK1 OK2 OK4 OK8 OL2 OL4 OLB OMP ON1 ON2 ONN OO1 OO2 OO3 OO4 OO5 OO6 OO7 OO8 OOA OON OOZ OP1 OP2 OP3 OP4 OP5 OP6 OP7 OP8 OPA OPB Plan / Benefit Description RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 SH-OREGON METRO AREA BASIC SH-OREGON METRO PRT B ONLY SH-OR BENT/LINN/LANE BASIC SH-OR BENT/LINN/LANE PRT B SH-OREGON MARION/PLK BASIC SH-OREGON MARION/PLK PRT B OHP MENTAL HEALTH BENEFIT OR INFERTILITY TREATMENT NAT'L PLN 2 $10 GR 06 10/100% NON-AARP GR08 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 10-20/250A NON-AARP GR08 NAT'L PLN 1 $5 GRP RET NAT'L PLN 1 $5 GR 06 15/250A NON-AARP GR08 10 BO HRLY NO-AARP GR08 TEST CODE NAT'L PLN 2 $10 GRP RET NAT'L PLN 1 $5 GRP RET NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET 10/100% NON-AARP GR08 NAT'L PLN 2A $10 GRP RET 10-20/250A AARP GR08 NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET 15-25/500A AARP GR08 OUT OF AREA PLAN POS - OUT OF AREA OUT OF AREA PLAN (COBRA) OHP - 100 FPL OHP - 133 FPL ADULT OHP - 133 FPL CHILD OHP - GENERAL ASSIST OHP-100 FPL (MENTAL ONLY) OHP-MEDICAL COVERAGE OHP-FPL CHILD MENTAL ONLY OHP-GEN. ASST. MENTAL ONLY OPEIU $0 OPEIU $0 COBRA 420 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit OPC OPD OPE OPZ OR1 OR2 OR3 OR4 OR5 OR6 OR7 OR8 ORA ORX OS1 OS2 OS3 OS4 OS5 OS6 OS7 OS8 OSA OSB OSC OSD OSE OSF OSG OSH OSJ OSK OSL OSU OSY OTO OTZ OUB OUZ OWA OWM P1C P1Z P2C P2P P2Z P3C P3P P3Z P4P Plan / Benefit Description OPEIU OPEIU COBRA OPEIU LOCAL 11 OPEIU LOCAL 11 COBRA SH-OREGON METRO AREA BASIC SH-OREGON METRO PRT B ONLY SH-0REGON BENT/LINN BASIC SH-OREGON BENT/LINN PRT B SH-OREGON LANE BASIC SH-OREGON LANE PRT B ONLY SH-OREGON MARION/PLK BASIC SH-OREGON MARION/PLK PRT B 5/100% AARP GR08 OTHR RX NOT THRU RX SOL SH-OREGON METRO AREA BASIC SH-OREGON METRO PRT B ONLY SH-OR BENT/LINN/LANE BASIC SH-OR BENT/LINN/LANE PRT B OR-SH STD PLN OR-SH STD PLN PART B SH-OREGON MARION/PLK BASIC SH-OREGON MARION/PLK PRT B OR - SH STD PLAN OR - SH STD PLAN PART B NORTHERN SH $10/$20/$100 SOUTHERN SH $15/$30/$200 SH INDIVIDUAL PART B OR SH SOUTHERN STD PLAN 05 OR SH NORTHERN STD PLAN OR SH SOUTHERN STD PLAN OR SH NORTHERN STD PLAN 05 OR SH STANDARD PART B 05 OR SH VALUE PLAN 05 OSU POS $10/100%/75% OSU POS $10/100%/75% CBRA 10/100% AARP GR08 20-40/250A AARP GR08 5/100% AARP GR08 5/100% NON-AARP GR08 OR PEBB-GR 10/150D PEBB NO-AARP GR08 94-CF-500 94-CF-500 COBRA CF500 (REVISED) RESERVED PPO CF500 COBRA (REVISED) CF-500 RESERVED PPO CF-500 COBRA RESERVED PPO 421 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit P5P P6H P6P P7H P7P P8L P8P P9P PA2 PA3 PA4 PA5 PA6 PA7 PA8 PA9 PAA PAB PAC PAD PAE PAF PAG PAH PAJ PAK PAM PAN PB1 PB4 PB6 PBH PBI PBL PBR PC1 PC7 PCF PCG PCH PCI PCJ PCK PCL PCM PCQ PD6 PDQ PED PEP Plan / Benefit Description RESERVED PPO UNAVAIL USED IN WA CLARK RESERVED PPO 15-30/200A PEBB V GR07 RESERVED PPO 15-30/200A PB NON-AARP GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PPO - PFFS PPO - PFFS PPO ADMINISTRATIVE CHARGE PPO - PFFS PPO - PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS SV 20-30/200A PEPSI 06 RESERVED PFFS SV 20-30/200A PEPSI 06 CB PERSONAL ASSIST. NETWORK $7G/$7BR BOEING RE $10G/$20BR/$30NF $5G/$5B TRI-MET UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK $10G/$25B/$40NF SH-PERS LINN/BENTON SH PERS 7 LINN BENTON UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV $15-$30/$100A PHS SV $15-$30/$100A PHS CB UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 20-40/200A PHS 06 SV 20-40/200A PHS 06 CB SV 30/500A PRINT S&P 08 PDV CUSTOM DENTAL & VISION SV 30/500A PRINT S&P 08 CB UNAVAILABLE USED IN WA $5/$15/$30 PEPSI CUSTOM RX 422 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit PF2 PF3 PF4 PF5 PF6 PF7 PF8 PF9 PFC PFD PH2 PH3 PH4 PH5 PH6 PH7 PH8 PH9 PIA PIB PIC PID PIE PIF PIG PIH PII PIK PIL PIN PIO PJ7 PJ8 PJL PJP PK7 PK8 PKA PKB PLP PLW PNA PNB POA POC POM PP1 PP7 PPA PPB Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SH MARION/POLK B ONLY SH MARION/POLK B ONLY NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SP 10/80%-60% SP 10/80%-60% CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 20-30/200A PEPSI 07 SV 20-30/100D PBG 07 DO NOT USE CLK CNTY CODE DO NOT USE CLK CNTY CODE SP 10/100% SP 10/100% CB PAYMENT LAG PREMIUM ALLOC 25% PORTABILITY SP 10/200D-60% SP 10/200D-60% CB POS OUT OF AREA POS OUT OF AREA SM GRP PCOR OPMH REIMBURSEMENT SH-PERS PORTLAND SH PERS 7 RESERVED PPO RESERVED PPO 423 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit PPC PPD PPE PPF PPG PPH PPJ PPK PPL PPM PPQ PPR PPS PPT PPU PPV PPW PPX PPY PPZ PQ7 PQ8 PQK PR1 PR2 PRD PRE PRK PRP PRT PRY PS1 PS2 PS5 PS6 PS7 PS8 PS9 PSC PSI PSK PSP PSQ PSZ PTK PTL PVA PVE PVG PVK Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PP&L MOD STAND 10 PLAN RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PP&L MOD STAND 10 COBRA UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SP 10/80% 08 PREFERRED PLAN PREFERRED PLAN PREMIUM DELAY PREFERRED PLAN $O ER COPAY SP 10/80% 08 CB PREFERRED PLAN-POS $10G/$20B PORT PREFERRED PLAN-POS (COBRA) SV 30/500A PRINT SPEC SV 30/500A PRINT SPEC CB SV 30/500A PRINT SPC 05 SV 30/500A PRINT SPC 05 CB PERS-MEDICARE ELIGIBLE SH MARION/POLK SH MARION/POLK SEBB PLAN - 94 $20/$200 PEPSI SP 10/100% 08 SV $20/$200A PEPSICO SV $20/$200A PEPSICO CB $20/$200 PEPSI COBRA SP 10/100% 08 CB SV 20-30/200A PEPSI 07 CB SP 10/100% 07 SP 10/200D 07 SP 10/80% 07 SP 10/80% 07 CB 424 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit PVL PVY PW5 PW8 PW9 PWA PXK PYI PYK PYQ PZ1 PZ2 PZA PZC PZE PZK Q1A Q1Z Q2A Q2C Q2Z Q3C Q4C Q5C Q5D Q5E Q5F Q6C Q7C QAC QC1 QC2 QC5 QC6 QCC QD3 QD4 QE1 QE2 QE3 QE4 QE5 QE6 QE7 QE8 QF1 QF2 QF3 QF4 QH1 Plan / Benefit Description SP 10/200D 07 CB SP 10/100% 07 CB PEBB-WA SECURE HORIZONS PEBB SH SH-PEBB $10 OR PEBB-GR SP 10/200D 08 RESERVED PFFS SV 30/500A PRINT SPEC 07 SV 30/500A PRINT SPEC 07CB PREFERRED PLAN (COBRA) PREFERRED PLAN (2) COBRA POS OUT OF AREA COBRA POS OUT OF AREA SMGRP CBRA PREFERRED $0ER COPAY COBRA SP 10/200D 08 CB 00-FB 2500 SMALL GROUP 00-FB 2500 SMALL GRP COBRA 00-FB 2500 INDIVIDUAL PLAN I 00-FB 2500 COBRA PORTABILITY LOW COST PLAN INDIVIDUAL PLAN I 1998 PORTABILITY LOW COST 1-99 2002 LOW COST PORTABILITY PORTABILITY LOW COST RESERVED SIGVALUE25/500DC INDIVIDUALPLAN I 2000-2001 INDIVIDUAL PLAN I SV 30/100D 06 ADVANTAGE $20/$500 ADVANTAGE $20/$500 COBRA ADVANTAGE $20/$500 SG ADVANTAGE $20/$500 SG CBRA SV 30/500D 06 NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV $20/$500D SV $20/$500D CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV $20/$500D SG SV $20/$500D SG CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV 20/250A SV 20/250A CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE PREFERRED $20/$250 425 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit QH2 QI3 QI4 QIC QJ3 QJ4 QK1 QK2 QK3 QK5 QK6 QK7 QK8 R10 R15 R1C R1Z R3C R3Z R4C R4Z R50 R5C R5Z R6C R6Z RA1 RA3 RA4 RB3 RB5 RB7 RB8 RBA RBB RBC RC1 RC2 RC5 RC6 RCM RFA RFF RFH RG0 RG1 RG2 RG3 RG4 RG5 Plan / Benefit Description PREFERRED $20/$250 COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE INDIVIDUAL PLAN I NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE ADVANTAGE $20/$500 ADVANTAGE $20/$500 COBRA NOT AVAIL CLK CNTY CODE ADVANTAGE $20/$500 SG ADVANTAGE $20/$500 SG CBR NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE O/P PRESCR DRUGS $100 DED $15 OR 50% 94-DE-3000 PLAN 94-DE-3000 PLAN COBRA CUSTOM DE3000 CUSTOM DE3000 $10/250 HMO TCI/PRIMESTAR $10/250 HMO TCI COBRA O/P PRESCRIP DRUGS $50 DED $10/250 NAT'L ACT PLAN $10/250 NAT'L ACCT PLANCBR DE-3000 DE-3000 COBRA RITE AID UNAVAIL USED IN WA CLARK SV 20/250A RITE AID 05 $3/$8/$23 $5/$10/$25 $7/$12/$27 $8/$13/$28 $10/$15/$30 $15/$25/$40 $15/$25/$40 ADVANTAGE $10/$200 ADVANTAGE $10/$200 COBRA ADVANTAGE $10/$200 SG ADVANTAGE $10/$200 SG CBRA $10 MAIL UNAVAIL USED IN WA CLARK SV 20/250A RITE AID 06 SV 20/250A RITE AID 06 CB $10G/$15B/$30NF RE $10G/$20B RETIREE $10G/$35B RETIREE $15G/$25B/$40NF $200 DED $15G/$25B/$40NF RE $5G/$10B 426 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit RG6 RG7 RG8 RG9 RH8 RHD RHJ RJ1 RJ2 RK1 RK2 RK5 RK6 RKI RKQ RKU RKV RKW RKY RM3 RM5 RM7 RM8 RMA RMI RMQ RMR RMU RMV RMW RMY RN1 RN2 RN3 RN4 RN5 RN6 RNG RNH RNJ RNK RNL RNP RNY RP5 RP8 RPA RPB RPC RPE Plan / Benefit Description $5G/$15B RETIREE $5G/$25B RETIREE $7G/$12B/$27NF RE $5G/$10B/$25NF RET $8 MAN GEN SV 15/90% 07 SV 15/90% 07 CB SV 10/200D SV 10/200D CB ADVANTAGE $10/$200 ADVANTAGE $10/$200 COBRA ADVANTAGE $10/$200 SG ADVANTAGE $10/$200 SG CBR ARP MCC NO EP-PL SH08 ARP MCC NO PP-PL SH08 ARP MCC NO PP SH08 ARP MCC NO PLUS SH08 ARP MCC NO SH08 ARP MCC NO EP SH08 $3 MAN GEN $5 MAN GEN $7/$7+DIF $8 MAN GEN $10 MAN GENERIC ARP MCC ES NO EP-PL SH08 ARP MCC ES NO PP-PL SH08 $15G/$20B/$30NF ARP MCC ES NO PP SH08 ARP MCC ES NO PLUS SH08 ARP MCC ES NO SH08 ARP MCC ES NO EP SH08 $7G/$14B GRP RET $10G/$20B GRP RET $10G/$25B GRP RET $10G/$20B/$40NF $10G/$20B/$50NF $15G/$25B/$40NF $7G/$14B $10G/$20B $10G/$25B $10G/$20B/$40NF $15G/$25B/$40NF NEC AMERICA OPTION PLAN NEC AMERICA OPTION PLAN CB $5G/$15B $8G/$13B POS $10/100%/60% POS $10/100%/60% COBRA THRIFTY PAYLESS PLAN RESPITE/PERS CARE SH07 427 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit RPX RPZ RR0 RSC RSZ RT3 RT5 RT7 RT8 RTA RTB RTC RTL RUC RUZ RVC RVZ RW7 RX0 RX1 RX2 RX3 RX4 RX5 RX8 RXA RXG RXH RXN RXP RZ1 RZ4 RZA RZH S10 S12 S52 SA2 SA3 SA4 SAF SAZ SBO SC1 SC2 SE0 SE1 SE3 SE5 SE7 Plan / Benefit Description RESPITE/PERS CARE WL-SH08 THRIFY PAYLESS PLAN COBRA $5G/$10B/$25NF 1X MO RET SEBB SEBB COBRA $3G/$8B $5G/$10B $7G/$12B $8G/$13B $5G/$10B $10G/$20B $5G/$10B DUMMY OHSU CUSTOM PLAN EFF 1-00 OHSU CUSTOM PLAN CBR 1-00 PEBB PEBB COBRA EFF 1-99 UNAVAIL USED IN WA CLARK $0 $1 $2 $3 $4 $5 $8 25% 50% TO $25 50% UPTO $25 %50 50% TO $50 RITE AID COBRA SV 20/250A RITE AID 05 CB SV 15/90% 08 SV 15/90% 08 CB SHARE PLAN 10-20 SHARE PLAN (PACIFICARE EE) STANDARD 5 PLAN STANDARD 10 PLAN AGILENT $20/100A AGILENT $20/100A COBRA SAFEWAY/VONS SAFEWAY/VONS COBRA SH BOEING NORTH AMERICAN PREMIER $15/100% PREMIER $15/100% COBRA SECURE HORIZONS PLUS SECURE HORIZONS PLUS SH PLUS 3 SH PLUS 5 SH PLUS 7 428 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit SE9 SEB SED SEJ SER SF0 SF1 SF3 SF5 SF8 SF9 SFC SFD SFW SFZ SG1 SG2 SG3 SG5 SG7 SGC SGJ SGL SGM SHE SHF SHP SHS SJ1 SJ3 SJ5 SJ7 SJE SJG SJM SK1 SK2 SKM SOC SOD SP1 SP3 SP5 SP7 SP9 SR0 SR1 SR3 SR5 SR7 Plan / Benefit Description SEC.HORIZONS-EMPLOYER SEBB PLAN SV 20/80% 07 SV 20/80% 07 CB SUPP ELIGIBILITY RIDER SECURE HORIZONS B ONLY SECURE HORIZONS B ONLY SH METRO AREA B ONLY SECURE HORIZONS B ONLY SH METRO AREA B ONLY SECURE HORIZ. B ONLY PLAN SPLIT FAMILY COVERAGE $10/$30/$60 SF SAFEWAY/VONS $20/250A SAFEWAY/VONS $20/250A CBRA SECURE HORIZONS PLUS 10 THE BASIC HEALTH PLAN SECURE HORIZONS PLUS 3 SECURE HORIZONS PLUS 5 SECURE HORIZONS PLUS 7 SV 20/250A SAFEWAY 06 SV 20/250A SAFEWAY 06 CB UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SECURE HORIZ. PLUS B ONLY SECURE HORIZ. B ONLY PLAN SECURE HORIZONS PLUS PLAN SECURE HORIZONS PLAN SECURE HORIZONS RET GRP 10 SECURE HORIZONS RET GRP 3 SECURE HORIZONS RET GRP 5 SECURE HORIZONS RET GRP 7 SV 20/250A SAFEWAY 07 SV 20/250A SAFEWAY 07 CB SV 20/250A SAFEWAY 08 PREMIER $15/100% PREMIER $15/100% COBRA SV 20/250A SAFEWAY 08 CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SUPPLEMENTAL LIFE BENE SECURE HORIZONS PLUS 3 SECURE HORIZONS PLUS 5 SECURE HORIZONS PLUS 7 SECURE HORIZONS PLUS PLAN SH GRP RETIREE $10 SEARS PLAN SH-GRP RETIREE $3 SH-GRP RETIREE $5 SH GRP RETIREE $7 429 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit SRS SRZ SS0 SS1 SS3 SS5 SS8 SS9 SSP SSR ST1 ST2 STD STF STM STX SW1 SW2 SW3 SW4 SW7 SX1 SX3 SX5 SX7 SYN SZ0 SZ1 SZ2 SZB SZN SZR T10 T1C T2C T2D T2E T2F T3P T4P TAX TCS TCU TD1 TD2 TK1 TK2 TK3 TK4 TL1 Plan / Benefit Description SEARS SEARS PLAN (COBRA) SECURE HORIZONS STANDARD SECURE HORIZONS STANDARD SH METRO AREA SECURE HORIZONS STANDARD SH METRO AREA SECURE HORIZONS STANDARD SH SILVER SNEAKERS SLV SNEAK/FITNESS BEN GR06 STANDARD PLAN STANDARD PLAN (2) RESERVED FOR PPO LIFE STATE FARM 20-30/250A SH TRI-MET RET GRP $5 STATE FARM 20-30/250A CBRA UNAVAIL USE IN WA CLARK UNAVAIL USE IN WA CLARK SV 20/250A SAFEWAY SV 20/250A SAFEWAY CB UNAVAIL USED IN WA CLARK SECURE HORIZONS RET GRP 10 SECURE HORIZONS RET GRP 3 SECURE HORIZONS RET GRP 5 SECURE HORIZONS RET GRP 7 SV 20/80% 08 SHARE PLAN 10-20 COBRA STANDARD PLAN (COBRA) STANDARD PLAN (2) COBRA SEBB PLAN COBRA SV 20/80% 08 CB SEARS COBRA $10G/$15B PORTABILITY PREVAIL PLAN OREGON PREVAILING PORTAB 2002 PREVAILING PORTABILTY PORTABILITY PREVAILING RESERVED SIGVALUE15/100DC UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK PCOR PREMIUM TAX SV 25/70% 07 SV 25/70% 07 CB PREFERRED $10/$250 PREFERRED $10/$250 COBRA PREFERRED $10/$250 PREFERRED $10/$250 COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE VALUE PLAN ($1600 FAM MAX) 430 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit TL2 TL3 TM1 TM2 TM6 TM7 TNC TP1 TP2 TP3 TP5 TP6 TPA TPB TPE TPF TPH TPL TS1 TS2 TSA TSB TSE TSF TTH TTL TW7 TW8 TYB TZ1 TZ2 TZ3 TZB U01 U02 U03 U04 U05 U06 U07 U08 U09 U10 U11 U12 U13 U14 U15 U16 U17 Plan / Benefit Description TELEDYNE WAH CHANG PLAN $5/50 HMO ORE-MET WAH CHAN CREDENCE SYS $15/$250A CREDENCE SYS $15/$250A CBR SV $15/$250A CREDENCE SV $15/$250A CREDENCE CB UNAVAI DON'T USE WA CODE POS $10/$200/60% POS $10/$200/60% COBRA TOWERS PERRIN $15 PLAN POS $10/$200/60% SG POS $10/$200/60% SG COBRA POS $10/$200/60% POS $10/$200/60% COBRA RESERVED RESERVED 5-10/100% GR06 15-20/100A GR06 POS $10/$200/75% POS $10/$200/75% COBRA POS $10/$200/75% POS $10/$200/75% COBRA POS $10/$200/75% SG POS $10/$200/75% SG COBRA DUMMY DUMMY UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 25/70% 08 VALUE (COBRA)(2X FAM MAX) TELEDYNE WAH CHANG COBRA $5/50 HMO ORE-MET WAH COBR SV 25/70% 08 CB USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO 431 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit U18 U19 U20 U21 U22 U23 U24 U25 U26 U27 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U42 U43 U44 U45 U46 U47 U48 U49 U50 U51 U52 U53 U54 U55 U56 U57 U58 U59 U60 UCW UCZ UHC UM0 UM3 UNA UNC Plan / Benefit Description USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO VSUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PP USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK DUAL-OPTION - UHC 06 UMTA $10/100% UMTA $3/100% UNAVAIL USED IN WA CLARK UWAA (CUSTOM $5 PLAN) 432 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit UNZ UPC UPZ UTC UZ0 UZ3 V00 V05 V07 V0A V12 V15 V1C V1M V1P V1X V1Y V1Z V25 V27 V2C V2F V2P V2Y V2Z V3C V3Z V8P V8Q V8R V8S V8T V8U V8V V8W V8X V9C V9Z VA2 VA3 VAA VAB VAC VAD VAE VAF VAG VAH VAI VAJ Plan / Benefit Description UWAA (CUSTOM $5 PLAN)COBRA UWAA $5 CUSTOM PLAN UWAA $5 CUSTOM PLAN COBRA TAKING CHARGE OF YOU UMTA $10/100% COBRA UMTA $3/100% COBRA VISION CARE $0 VSP VISION CARE $10.00(SEBB) VISION CARE $7 (VSP) VISIONCARE $10 PEBB 1-99 VISION CARE $12 (VSP) VISION CARE $15 (VSP) 94-EB-1500 94-EB-1500 IPGB ADVANTAGE PLAN OPTION 94-EB-1500 IPGB ADVANTAGE PLAN OPTION CBR 94-EB-1500 COBRA VISION - THRIFTY/PAYLESS SC 20 ELIGIBILITY ONLY EB-1500 20% PLAN 25/70A TOWERS GR-VN06 VSP 94-EB-1500-OPTION 94-EB-1500-OPTION COBRA EB-1500 20% PLAN COBRA' 00-EB-1500 00-EB-1500 COBRA 0 REFRAC 1/V YR VN-GR08 5 REFRAC 1/V YR VN-GR08 10 REFRAC 1/V YR VN-GR08 15 REFRAC 1/V YR VN-GR08 20 REFRAC 1/V YR VN-GR08 25 REFRAC 1/V YR VN-GR08 30 REFRAC 1/V YR VN-GR08 35 REFRAC 1/V YR VN-GR08 40 REFRAC 1/V YR VN-GR08 EB-1500 20% SMALL GROUP EB-1500 20% SMALL GRP COBR VALUE PLAN $10 VISION OHSU $10 OPTION A EXAM/HRDWARE $10 OPTION B EXAM/HRDWARE VSP $10 EXAM ONLY VISION CARE $15 1-99 VSP $35 EXAM ONLY VSP $5 EXAM ONLY VSP $15 EXAM ONLY VSP $20 EXAM ONLY VSP $25 EXAM ONLY $5 OPTION A EXAM/HARDWARE 433 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit VAK VAL VAM VAN VAO VAP VAQ VAR VB6 VBC VBH VBJ VBK VBL VBM VBN VBO VBZ VC0 VC1 VC2 VC5 VC6 VCB VCC VDA VE1 VE3 VE7 VEO VEP VEY VFA VFD VFP VFQ VG6 VGC VGP VGQ VGS VGZ VI3 VI4 VI7 VI8 VJQ VK3 VK4 VKP Plan / Benefit Description $15 OPTION A EXAM/HRDWARE $20 OPTION A EXAM/HRDWARE $25 OPTION A EXAM/HRDWARE $0 OPTION A EXAM/HARDWARE $3 OPTION A EXAM/HARDWARE VSP $0 EXAM ONLY 30/70A 2YRS SH-VN07 VSP $3 EXAM ONLY 25/150A 2 YRS SH-VN06 00-EB 1500 SMALL GROUP $15/$75 BOEING HRLY GP RET $5 OPTION B EXAM/HRDWARE $15 OPTION B EXAM/HRDWARE $20 OPTION B EXAM/HRDWARE $25 OPTION B EXAM/HRDWARE $0 OPTION B EXAM/HARDWARE $3 OPTION B EXAM/HARDWARE 00-EB 1500 SMALL GRP COBRA VSP $15 EXAM ONLY CHILD ADVANTAGE $15/$300 ADVANTAGE $15/$300 COBRA ADVANTAGE $15/$300 SG ADVANTAGE $15/$300 SG CBRA BOEING ERET VISN $15 (VSP) BOEING ERET VISN $10 (VSP) 15/70A GR-VN07 UNAVAIL USED IN WA CLARK SH PLUS 3 SECURE HORIZONS PLUS 7 35 EXAM ONLY VSP ADVANTAGE PLAN - EOFF ADVANTAGE PLAN EOFF COBRA 30 EXAM FEDS VN06-PDV PDV $40 EXAM ONLY FED 2005 0/75A 2YRS VN-GR08 0/125A 2YRS VN-GR08 25/75A VN-GR06 GOOD SAMARITAN HOS PLAN 5/75A 2YRS VN-GR08 5/125A 2YRS VN-GR08 VISION CARE - EUGENE SCHLS GOOD SMRTN HOS PLAN COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE NOT AVAIL. C CNTY CODE NOT AVAIL. C CNTY CODE 10/75A 2YRS VN-GR08 NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE 10/125A 2YRS VN-GR08 434 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit VL6 VMQ VMU VMZ VN1 VN2 VN5 VNQ VOA VOB VOC VOD VOE VOF VPA VPE VPP VPS VPV VPZ VQD VQP VSQ VVP VVQ VWP VYP VZ2 VZC W1C W1Z W2C W3C W4C W4Z W5C W6C WAB WAC WAD WAJ WAL WAP WBJ WBL WC1 WC2 WCE WCH WCJ Plan / Benefit Description ADV WELLNESS LITE SH-WL06 15/125A 2YRS VN-GR08 MULTNOMAH BAR ASSOC MULTNOMAH BAR ASSOC COBRA GRP RET $5OV/$125 ALLOWNCE GRP RET $10OV/$75 ALLOWNCE GRP RET $20V/$75 ALLOWANCE 20/75A 2YRS VN-GR08 POS $15/90%/65% POS $15/90%/65% COBRA NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE POS $15/90%/65% SG POS $15/90%/65% SG COBRA VISION PREMIUM ALLOCATION RESERVED PFFS 20/125A 2YRS VN-GR08 $30 PRINT SPEC VSP 10/150A 2YRS PEBB GR-VN07 25/150A 2YRS PEBB GR-VN07 30/70A 2YRS VN-SH08 25/70A 2YRS VN-GR08 30/70A 2YRS SH-VN07 15/75A 2YRS VN-GR08 25/75A 2YRS VN-GR08 25/125A 2YRS VN-GR08 10/150A 2YRS PEBB VN-GR08 VALUE PLAN (COBRA) 25/150A 2YRS PEBB VN-GR08 94-EE-3000 PLAN 94-EE-3000 PLAN COBRA INDIVIDUAL PLAN II INDIVIDUAL PLAN II EE-3000 EE-3000 COBRA INDIVIDUALPLANII 2000-2001 INDIVIDUAL PLAN II UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL DON'T USE WA CODE WEIGHT ALTERATION PROGRAMS SV 25/70% SG07 UNAVAIL DON'T USE WA CODE PREMIER $15/70% PREMIER $15/70% COBRA UNAVAIL USED IN WA CLARK SP 15/90% WILLAMETTE 05 SV 25/70% SG07 CB 435 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit WCK WCL WCM WCN WCP WD1 WD2 WD3 WD4 WE1 WE2 WE3 WE4 WE5 WE6 WE7 WE8 WEC WEZ WF1 WF2 WF3 WF4 WF5 WF6 WF7 WF8 WFB WFD WFE WFJ WFX WFZ WG7 WG8 WGC WGZ WH7 WH8 WHA WHG WHZ WIC WJ1 WJ2 WJ5 WJ6 WJP WJY WK1 Plan / Benefit Description SP 15/90% WILLAMETTE 05 CB SP 20/80% WILLAMETTE 05 SP 20/80% WILLAMETTE 05 CB UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 15/90% SV 15/90% CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV $20/80% SV $20/80% CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV $20/80% SG SV $20/80% SG CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE EUGENE PUBLIC SCHOOLS EUGENE PUBLIC SCHOOLS SV $25/70% SV $25/70% CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE SV $25/70% SG SV $25/70% SG CB NOT AVAIL CLK CNTY CODE NOT AVAIL CLK CNTY CODE WELLS FARGO BANK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK WELLS FARGO BANK COBRA UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK EUGENE PUBLIC SCHOOLS EUGENE SCHLS - COBRA UNAVIL USED IN WA CLARK UNAVIL USED IN WA CLARK KUNI $15/$200 SV 15-30/100D OPEIU 08 KUNI $15/$200 COBRA INDIVIDUAL PLAN ADVANTAGE $15/$300 ADVANTAGE $15/$300 COBRA ADVANTAGE $15/$300 SG ADVANTAGE $15/$300 SG CBR JOSEPHINE COUNTY JOSEPHINE COUNTY (COBRA) PREMIER $15/70% 436 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit WK2 WK5 WK6 WK7 WK8 WLA WME WMG WMN WMP WNC WNF WPA WPC WPY WUR WUS WUT WVR WVS WVT WWF WXR WXS WXT X10 X15 X1A X1B XAV XAY XAZ XJA XJB XJC XM1 XM3 XM5 XM7 XM8 XS1 XS5 XS7 XS8 XXX Z2X Z5V Z8X ZA2 ZA3 Plan / Benefit Description PREMIER $15/70% COBRA PREMIER $15/70% SG PREMIER $15/70% SG COBRA DO NOT USE CLK CNTY CODE DO NOT USE CLK CNTY CODE 36AVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK SV 15-30/100D OPEIU 08 CB UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK INDIVIDUAL PLAN II SV 25/70% SG 08 KUNI $15/$200/75% IPGB - BASIC PLAN KUNI $15/$200/75% COBRA 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 SV 25/70% SG 08 CB 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 $10 $15 $10 $10 PPO DUMMY DUMMY DUMMY $5 MAND. GENERIC $10 MAND. GENERIC $15 $10/10+DIF $3/$3 + DIFF $5/$5+DIF $7/$7+DIF $8/$8+DIF $10 $5 $7 $8 NO BENEFIT 10-15/50A T1A NON-AARP GR8 15-25/130D T2B NO-AARP GR8 10-20/200A T1C NO-AARP GR8 RESERVED PPO RESERVED PPO 437 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit ZA4 ZA5 ZA6 ZA7 ZA8 ZA9 ZB2 ZB3 ZB4 ZB5 ZB6 ZB7 ZB8 ZB9 ZBL ZC2 ZC3 ZC4 ZC5 ZC6 ZC7 ZC8 ZC9 ZCE ZCN ZCP ZD2 ZD3 ZD4 ZD5 ZD6 ZD7 ZD8 ZD9 ZE2 ZE3 ZE4 ZE5 ZE6 ZE7 ZE8 ZE9 ZF2 ZF3 ZF4 ZF5 ZF6 ZF7 ZF8 ZF9 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO NOT AVAIL CLK CNTY CODE RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK UNAVAIL USED IN WA CLARK RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 438 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit ZG2 ZG3 ZG4 ZG5 ZG6 ZG7 ZG8 ZG9 ZH2 ZH3 ZH4 ZH5 ZH6 ZH7 ZH8 ZH9 ZJ2 ZJ3 ZJ4 ZJ5 ZJ6 ZJ7 ZJ8 ZJ9 ZK2 ZK3 ZK4 ZK5 ZK6 ZK7 ZK8 ZK9 ZM2 ZM3 ZM4 ZM5 ZM6 ZM7 ZM8 ZM9 ZN2 ZN3 ZN4 ZN5 ZN6 ZN7 ZN8 ZN9 ZP2 ZP3 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 439 of 640 Plan Benefit - OR State OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR Plan / Benefit ZP4 ZP5 ZP6 ZP7 ZP8 ZP9 ZR2 ZR3 ZR4 ZR5 ZR6 ZR7 ZR8 ZR9 ZZZ Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO HISTORICAL PLAN 440 of 640 Plan Benefit - TX Cap/Eligibility CP7810 Assigned Plan Benefit Codes & Descriptions State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 0AZ 0BZ 0CZ 0DZ 0HM 13A 1AZ 1BZ 1CZ 1DZ 1EZ 1HM 1JZ 1LZ 1RZ 1SA 1U5 1UA 1UB 203 2AN 2AY 2AZ 2BL 2BZ 2C1 2C2 2C3 2C5 2CG 2CH 2CJ 2CK 2CZ 2DZ 2FH 2FL 2G1 2G2 2G3 2GH 2HH Plan / Benefit Description PPO PLAN10 15 80/60 250 CB PPO PLAN10 15 80/60 250 CB PPO PLAN10 15 80/60 250 CB PPO PLAN10 15/80/60 250 CB FLEX PREF 99 DUMMY PPO PLAN1 15 90/70 250 CBR PPO PLAN1 15 90/70 250 CBR PPO PLAN1 15 90/70 250 CBR PPO PLAN1 15 90/70 250 CBR PPO PLAN11 20 80/60 250 CB FLEX P10 99 PPO PLAN11 20 80/60 250 CB PPO PLAN11 20 80/60 250 CB PPO PLAN11 20 80/60 250 CB $5 $5 $10 $5 PLAN 20 4/20/40 LO GR-RX07 4/25/50 HI GR-RX07 PPO PLAN2 20 90/70 250 CBR 10/25/50 RX-GR08 PPO PLAN2 20 90/70 250 CBR $5G/$10B $10G/$15B $5G/$10B $7.50G/$15B $2G/$2B $7G / $15B $5G/$15B FEDS RX $10G/$20B PPO PLAN2 20 90/70 250 CBR PPO PLAN2 20 90/70 250 CBR 4/15/30 RX-GR08 5/20/45 RX-GR08 $7G/$14B $10G/$20B $10G/$25B 4/20/40 RX-GR08 4/15/30 RX-GR08 441 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 2HM 2I5 2IA 2IB 2JH 2KH 2MH 2NH 2PH 2QH 2S2 2S3 2S4 2SA 2U1 2U2 2U5 2U6 2UB 2UF 2UH 2UJ 2VH 2WH 2XH 2YH 2Z3 2ZA 2ZB 2ZC 2ZD 2ZE 2ZF 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 Plan / Benefit Description FLEX 1-10 99 $10G/$20B INDIVIDUAL PLAN $5G/$10B S GOLD $5G $15B SECURE GOLD 4/20/40 RX-GR08 4/25/50 RX-GR08 4/25/45 RX-GR08 4/28/55 RX-GR08 4/28/58 RX-GR08 4/25/50 RX-GR08 $10G/$30B SH $10G/$30B SH $10G/$30B $5G/$15B $5G/$10B $5G/$15B $10G/$20B $10G/$25B $5G/$15B $10G/$25B 10/25/50 RX-GR08 $5G/$15B 10/25/50 RX-GR08 5/20/45 RX-GR08 5/20/45 RX-GR08 4/10/20 RX-GR08 PLAN 20 - COBRA 0/0 GR-RX07 2/40 GR-RX07 5/25 GR-RX07 5/65 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 MANDATED OFFER RIDERS PPO INFERTILITY INVITRO PPO SPEECH & HEARING PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO 442 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 317 318 319 320 321 322 323 324 325 326 327 328 329 330 382 383 38H 3AZ 3BZ 3C1 3C2 3C3 3C4 3C5 3C6 3C7 3C8 3CA 3CB 3CC 3CD 3CF 3CT 3CZ 3DZ 3E1 3E2 3E3 3E4 3E5 3FA 3FC 3FD 3G1 3G2 3G3 3GA 3GB 3HM 3PC Plan / Benefit Description MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO 380 PLAN (2) 380 PLAN (3) $7G/15B PPO PLAN3 10 90/70 250 CBR PPO PLAN3 10 90/70 250 CBR $5/$20/$35 $5/$15/$25 $10/$20/$35 $5/$10/$10 $10/$20/$35 FT WORTH RET $5/$15/$30 $5/$10/$25 $5G/$10B/$10NF $15G/$20B/$30NF $5/$15/$25 $10/$30/$50 $5/$15/$30 $20G/$40B/$50NF $10G/$20B/$40NF PPO PLAN3 10 90/70 250 CBR PPO PLAN3 10 90/70 250 CBR 10/20/45 E 10/30/50 E 15/25/50 E 15/30/50E 1HD 15/35/60E 2HD 10/30/50 RX06 10/40/50 RX05 15/30/60 RX06 $15G/$25B/$40NF $10G/$20B/$50NF $10G/$20B/$40NF $15G/$25B/$40NF 15G/25B/40NF W/INJ FLEX PLAN 1 99 10/30/40 PHS 443 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 3PH 3QL 3TA 3U5 3U7 3U8 3U9 3UG 3UI 3UK 3UL 3Z2 3Z3 3ZE 3ZF 3ZG 3ZH 3ZJ 3ZK 3ZL 3ZM 40A 40B 40C 40D 40E 40F 40G 40H 40I 40J 40K 40L 40M 40N 40O 40P 40Q 40R 40S 40T 40U 40V 40W 40X 40Y 40Z 41A 41B 41C Plan / Benefit Description 10/30/50 RX06 5/15/30 RX 08 $10G/$30B/$55NF $5/$10/$25 $5/$15/$30 $5/$15/$35 $10/$20/$35 $5/$15/$30 $10/$20/$35 $5G/$10B/$25NF $10G/$15B/$25NF 380 PLAN (COBRA 2) 380 PLAN (COBRA 3) 5/10/20 GR-RX07 10/20/35 GR-RX07 10/20/35 GR-RX07 10/25/55 GR-RX07 10/40/75 GR-RX07 7/20/50% GR-RX07 2/30/60 GR-RX07 10/25/50 GR-RX07 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 444 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 41D 41E 41F 41G 41H 41I 41J 41K 41L 41M 41N 41O 41P 41Q 41R 41S 41T 41U 41V 41W 41X 41Y 41Z 42I 43I 440 44I 45I 46A 46I 47A 47I 48I 49I 49P 49Q 4A0 4A1 4AI 4AO 4AZ 4B0 4B1 4BI 4BO 4BZ 4C0 4C1 4CI 4CO Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO MCC 1 CC GR08 RESERVED RX PPO MCC 1 SA GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO MCC 1 DFW GR08 MCC 1 DFW DLX GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO PPO PLAN4 20 90/70 500 CBR RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO PPO PLAN4 20 90/70 500 CBR RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 445 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 4CZ 4D0 4D1 4DZ 4E0 4E1 4EI 4EO 4F0 4F1 4FI 4FO 4G0 4G1 4GI 4H0 4H1 4HI 4HM 4HO 4I0 4I1 4IA 4IB 4IC 4ID 4IE 4IF 4IG 4IH 4II 4IJ 4IK 4IL 4IN 4IO 4IP 4IQ 4IR 4IS 4IT 4IU 4IV 4IW 4IX 4IY 4IZ 4J0 4J1 4JI Plan / Benefit Description PPO PLAN4 20 90/70 500 CBR RESERVED RX PPO RESERVED RX PPO PPO PLAN4 20 90/70 500 CBR RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO FLEX 10/0/800 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 446 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 4JO 4K0 4K1 4KI 4KO 4L0 4L1 4LI 4M0 4M1 4MI 4MO 4N0 4N1 4NI 4NO 4O0 4O1 4OA 4OB 4OC 4OD 4OF 4OH 4OI 4OJ 4OK 4OL 4OM 4OO 4OP 4OQ 4OS 4OT 4OU 4OV 4OW 4OX 4OY 4OZ 4P0 4P1 4PI 4PO 4Q0 4Q1 4QI 4QO 4R0 4R1 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 447 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 4RO 4S0 4S1 4T0 4T1 4TI 4U0 4U1 4UI 4UO 4V0 4V1 4VI 4VO 4W0 4W1 4WI 4WO 4X0 4X1 4XI 4XO 4Y0 4Y1 4YI 4YO 4Z0 4Z1 4ZI 4ZO 50A 50B 50C 50D 50E 50F 50G 50H 50I 50J 50K 50L 50M 50N 50O 50P 50Q 50R 50S 50T Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 448 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 50U 50V 50W 50X 50Y 50Z 51A 51B 51C 51D 51E 51F 51G 51H 51I 51J 51K 51L 51M 51N 51O 51P 51Q 51R 51S 51T 51U 51V 51W 51X 51Y 51Z 52I 535 536 537 538 539 53I 540 541 542 543 544 545 546 547 548 549 54I Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO 449 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 550 551 552 553 554 555 556 557 558 559 55I 560 561 562 563 564 565 566 567 568 569 56I 570 571 572 573 574 575 576 577 578 579 57I 580 581 582 583 584 585 586 587 588 589 58I 590 591 592 593 594 59I Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO 450 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 5A0 5A1 5AA 5AI 5AO 5AX 5AZ 5B0 5BA 5BI 5BO 5BX 5BZ 5C0 5C1 5CA 5CI 5CO 5CX 5CZ 5D0 5D1 5DA 5DX 5DZ 5E0 5E1 5EI 5F0 5F1 5FI 5FO 5G0 5G1 5GI 5H0 5H1 5HI 5HM 5HO 5I0 5I1 5IA 5IB 5IC 5ID 5IE 5IF 5IG 5IH Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO HMO 5 RESERVED BENEFIT PPO RESERVED BENEFIT PPO PPO PLAN5 15 80/60 500 CBR HMO 5 COBRA RESERVED BENEFIT PPO HMO 5 RESERVED BENEFIT PPO RESERVED BENEFIT PPO PPO PLAN5 15 80/60 500 CBR HMO 5 COBRA RESERVED BENEFIT PPO RESERVED BENEFIT PPO HMO 5 RESERVED BENEFIT PPO RESERVED BENEFIT PPO PPO PLAN5 15 80/60 500 CBR HMO 5 COBRA RESERVED BENEFIT PPO RESERVED BENEFIT PPO HMO 5 PPO PLAN5 15 80/60 500 CBR HMO 5 COBRA RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO FLEX 10/100/1000 RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 451 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 5II 5IJ 5IK 5IL 5IN 5IO 5IP 5IQ 5IR 5IS 5IU 5IV 5IW 5IX 5IY 5IZ 5J0 5J1 5JI 5JO 5K0 5K1 5KI 5KO 5L0 5L1 5LI 5M0 5M1 5MI 5N0 5N1 5NI 5NO 5O0 5O1 5O2 5O3 5O4 5O5 5O6 5O7 5O8 5O9 5OA 5OB 5OD 5OF 5OH 5OI Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 452 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 5OJ 5OK 5OL 5OM 5ON 5OO 5OQ 5OS 5OT 5OU 5OV 5OW 5OX 5OY 5OZ 5P0 5P1 5PI 5PO 5Q0 5Q1 5QI 5QO 5R0 5RO 5S0 5S1 5S2 5S3 5SA 5SB 5SC 5T0 5T1 5TI 5U0 5U1 5UI 5UO 5V0 5V1 5VI 5VO 5W0 5W1 5WI 5WO 5X0 5X1 5XI Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO $5/100% HMO SMALL GRP CBRA $5/100% HMO SMALL GRP CBRA $5/100% HMO SMALL GRP CBRA $5/100% HMO SMALL GRP $5/100% HMO SMALL GROUP $5/100% HMO SMALL GROUP RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 453 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 5XO 5Y0 5Y1 5YI 5YO 5Z0 5Z1 5ZI 5ZO 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 454 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 6AH 6AL 6AZ 6BH 6BL 6BZ 6CP 6CZ 6DH 6DL 6DM 6DP 6DZ 6EH 6EL 6FH 6FL 6FR 6HH 6HL 6HM 6JH 6JL 6KH 6KL 6LH 6LL 6MA 6MH 6ML 6NH Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 0/0 HI GR-RX07 0/0 LO GR-RX07 PPO PLAN6 20 90/70 500 CBR 2/30/60 HI GR-RX07 2/30/60 LO GR-RX07 PPO PLAN6 20 90/70 500 CBR 8.50/26.15/50% SH6 PPO PLAN6 20 90/70 500 CBR 2/40 HI GR-RX07 2/40 LO GR-RX07 15/25/40 GR-RX06 8.50/26.15/50% SH6 PPO PLAN6 20 90/70 500 CBR 5/25 HI GR-RX07 5/25 LO GR-RX07 5/65 HI GR-RX07 5/65 LO GR-RX07 10/20 GR-RX06 5/10 HI GR-RX07 5/10 LO GR-RX07 FLEX 10/200/1000 5/10/20 HI GR-RX07 5/10/20 LO GR-RX07 7/14 HI GR-RX07 7/14 LO GR-RX07 7/20/50% HI GR-RX7 7/20/50% LO GR-RX7 10/25%/40% RX-GR06 10/20 HI GR-RX07 10/20 LO GR-RX07 10/20/40 HI GR-RX7 455 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 6NL 6PH 6PL 6PR 6QH 6QL 6QM 6RH 6RL 6SC 6SH 6SL 6TH 6TL 6UH 6UL 6VM 6VP 6WH 6ZM 710 711 712 713 714 715 716 717 718 719 71A 71B 71C 71D 71E 71F 71G 71H 71I 71J 71K 71L 71M 71N 71O 71P 71Q 71R 71S 71T Plan / Benefit Description 10/20/40 LO GR-RX7 10/20 HI GR-RX07 10/20 LO GR-RX07 10/20/40 GR-RX06 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 5/15/30 GR-RX06 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 10/25%/40% RX-GR06 10/25/55 HI GR-RX7 10/25/55 LO GR-RX7 10/40/75 HI GR-RX7 10/40/75 LO GR-RX7 15/25/40 HI GR-RX7 15/25/40 LO GR-RX7 5/5 GR-RX06 25%/25%/25% SH6 10/25/50 HI GR-RX7 7/14 GR-RX06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 456 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 71U 71V 71W 71X 71Y 71Z 720 721 722 723 724 725 726 727 728 729 72A 72B 72C 72D 72E 72F 72G 72H 72I 72J 72K 72L 72M 72N 72O 72P 72Q 72R 72S 72T 72U 72V 72W 72X 730 731 732 733 734 735 736 737 738 739 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVE PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 457 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 73A 73B 73C 73D 73E 73F 73G 73H 73I 73J 73K 73L 73M 73N 73O 73P 73Q 73R 73S 73T 73U 73V 73W 73X 73Y 73Z 740 741 742 743 744 745 746 747 748 749 74A 74B 74C 74D 74E 74F 74G 74H 74I 74J 74K 74L 74M 74N Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO VESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 458 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 74O 74P 74Q 74R 74S 74T 74U 74V 74W 74X 74Y 74Z 750 751 752 753 754 755 756 757 758 759 75A 75B 75C 75D 75E 75F 75G 75H 75I 75J 75K 75L 75M 75N 75O 75P 75Q 75R 75S 75T 75U 75V 75W 75X 75Y 75Z 760 761 Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED RX PPO RESERVED RX PPO 459 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 762 763 764 765 766 767 768 769 76A 76B 76C 76D 76E 76F 76G 76H 76I 76J 76K 76L 76M 76N 76O 76P 76Q 76R 76S 76T 76U 76V 7AQ 7AR 7AZ 7BD 7BH 7BI 7BL 7BR 7BZ 7CD 7CI 7CM 7CZ 7DD 7DH 7DL 7DM 7DR 7DZ 7ED Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 7/20 GR-RX07 0/0 GR-RX07 PPO PLAN7 10 80/60 500 CBR 7/14 GR-RX07 4/10/20 T1A H GRX7 7/14 I GR-RX07 4/10/20 T1A L GRX7 0/0 FLAT GR-RX07 PPO PLAN7 10 80/60 500 CBR 7/14 GR-RX07 7/14 I GR-RX07 15/25/40 GR-RX07 PPO PLAN7 10 80/60 500 CBR 7/20/30 GR-RX07 4/15/30 T1B H GRX7 4/15/30 T1B L GRX7 15/25/40 GR-RX07 10/10 FLAT GR-RX07 PPO PLAN7 10 80/60 500 CBR 7/7 GR-RX07 460 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 7EH 7EL 7EM 7ER 7FD 7FH 7FL 7FM 7FR 7GD 7GM 7GR 7HH 7HI 7HL 7HM 7HR 7JH 7JL 7JM 7JR 7KH 7KI 7KL 7KM 7KR 7LH 7LL 7LM 7LR 7MA 7MH 7MI 7ML 7MR 7NH 7NL 7NM 7PH 7PI 7PL 7PM 7PR 7Q2 7Q3 7QH 7QI 7QL 7QM 7QR Plan / Benefit Description 4/20/40 T1C H GRX7 4/20/40 T1C L GRX7 3/3 FLAT GR-RX07 10/20 GR-RX07 7/7 C GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 3/3/3 GR-RX07 10/20 GR-RX07 10/20/30 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 4/15/30 T2A H GRX7 10/20 I GR-RX07 4/15/30 T2A L GRX7 FLEX 10/250/1000 10/20 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/10 GR-RX07 10/10 GR-RX07 4/28/55 T3B H GRX7 10/20/35 I GR-RX07 4/28/55 T3B L GRX7 5/10/20 GR-RX07 10/20/35 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 5/15 GR-RX07 15/25/40 GR-RX07 10/25%/40% GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 10/20/40 GR-RX07 4/25/50 T2C H GRX7 4/25/50 T2C L GRX7 5/15/30 GR-RX07 4/25/50 T2C H GRX7 10/20/40 I GR-RX07 4/25/50 T2C L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 5/29/56.25W/G SHX7 5/29/55.40W/G SHX7 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 461 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 7RA 7RB 7RC 7RD 7RH 7RL 7RM 7SB 7SI 7SR 7TH 7TL 7TM 7TR 7UH 7UL 7UM 7UR 7VH 7VL 7VM 7WH 7WI 7WL 7WM 7WR 7XA 7XB 7XC 7XD 7XE 7XF 7XG 7XH 7XJ 7XL 7XM 7XP 7XU 7XV 7XW 7YH 7YI 7YL 7YM 7YR 7ZH 7ZL 7ZM 7ZR Plan / Benefit Description 10/20/35 RDS GRX7 10/20 RDS GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 4/15/30 T2A H GRX7 4/15/30 T2A L GRX7 5/15/30 GR-RX07 10/25%/40% GR-RX07 10/20/40 I GR-RX07 10/20/40 GR-RX07 4/28/55 T3B H GRX7 4/28/55 T3B L GRX7 5/5 GR-RX07 10/25/40 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/5 GR-RX07 15/25/40 GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 5/5 GR-RX07 4/20/40 T1C H GRX7 15/25/40 I GR-RX07 4/20/40 T1C L GRX7 5/7.50 GR-RX07 15/25/40 GR-RX07 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/25/50 RDS GR-RX7 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/15/30 T1B H GRX7 4/25/50 RDS GR-RX7 4/15/30 T1B L GRX7 7/14 GR-RX07 5/29/60 N/G SH-RX7 5/28/65 N/G SH-RX7 5/35/65 NGB SH-RX7 0/28/64 N/G SH-RX7 4/10/20 T1A H GRX7 15/25/40 I GR-RX07 4/10/20 T1A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 462 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 82A 82B 82C 82D 82E 82F 82G 82H 82J 82K 82L 82M 82N 82P 82Q 82R 82S 82T 82U 82V 82W 82X 82Y 82Z 830 831 832 833 834 835 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 463 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 836 837 838 839 83A 83B 83C 83D 83E 83F 83G 83H 83J 83K 83L 83M 840 841 842 843 844 845 846 847 848 849 84A 84B 84C 84D 84E 84F 84G 84H 84J 84K 84L 84M 84N 84P 84Q 84R 84S 84T 84U 84V 84W 84X 84Y 84Z Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 464 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 850 851 852 853 854 855 856 857 858 859 85A 85B 85C 85D 85E 85F 85G 85H 85J 85K 85L 85M 860 861 862 863 864 865 866 867 868 869 86A 86B 86C 86D 86E 86F 86G 86H 86J 86K 86L 86M 86N 86P 86Q 86R 86S 86T Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX POO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 465 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 86U 86V 86W 86X 86Y 86Z 87A 87B 87C 87D 87E 87F 87G 87H 87J 87K 87L 87M 882 883 88H 8AH 8AR 8AZ 8B8 8BH 8BZ 8CH 8CZ 8DD 8DH 8DP 8DR 8DZ 8ED 8EH 8EM 8ER 8FD 8FH 8G8 8GH 8GM 8H8 8HD 8HH 8HM 8HR 8KM 8L8 Plan / Benefit Description 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 880 PLAN (2) 880 PLAN (3) $5G/$20B POS 0/0 HI C GR-RX07 0/0 C GR-RX07 PPO PLAN8 20 80/60 500 CBR 5/29/60NG RX-SH08 DO NOT USE PPO PLAN8 20 80/60 500 CBR 2/30/60 HI C GRX07 PPO PLAN8 20 80/60 500 CBR 7/20/30 C GR-RX07 2/40 HI C GR-RX07 3/20/40/40 GR-RX07 10/10 FLAT C GRX07 PPO PLAN8 20 80/60 500 CBR 7/7 C GR-RX07 5/25 HI C GR-RX07 3/3 FLAT C GR-RX07 10/20 C GR-RX07 7/7 C GR-RX07 5/65 HI C GR-RX07 6/42/85NG RX-SH08 5/10 HI C GR-RX07 5/10 C GR-RX07 6/43/92NG RX-SH08 10/20/30 C GR-RX07 DO NOT USE FLEX 10/300/1200 3/20/40/40 RX-GR08 5/10/20 C GR-RX07 5/34/79NG RX-SH08 466 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 8LH 8LM 8M8 8MA 8N8 8NM 8PH 8PM 8Q8 8R8 8RH 8RM 8SH 8TH 8TM 8TR 8UM 8UR 8VM 8WH 8Z2 8Z3 910 911 912 913 914 915 916 917 918 919 91H 920 921 922 923 924 925 926 927 928 929 92H 930 931 932 933 934 935 Plan / Benefit Description 7/20/50% HI C GRX7 5/15 C GR-RX07 5/36/82NG RX-SH08 10/25%/40% C GRX07 5/29/60G RX-SH08 5/15/30 C GR-RX07 10/20 HI C GR-RX07 5/15/30 C GR-RX07 5/37/71G RX-SH08 5/37/71G RX-SH08 10/20/35 HI C GRX7 5/15/30 C GR-RX07 10/25/55 HI C GRX7 10/40/75 HI C GRX7 5/5 C GR-RX07 10/25/40 C GR-RX07 5/5 C GR-RX07 15/25/40 C GR-RX07 5/7.50 C GR-RX07 10/25/50 HI C GRX7 880 PLAN (COBRA 2) 880 PLAN (COBRA 3) RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15/25/40 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/25/50 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 467 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 936 937 938 939 93H 940 941 942 943 944 945 946 947 948 949 94H 950 951 952 953 954 955 956 957 958 959 95H 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20/40 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20 HI RX-GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/40/75 HI C XGR8 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 468 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 983 984 985 986 987 988 989 990 991 992 993 994 9AN 9AQ 9AR 9AY 9AZ 9BE 9BH 9BL 9BZ 9CM 9CZ 9DH 9DL 9DP 9DR 9DZ 9EH 9EL 9ER 9FD 9FH 9FL 9GE 9GM 9HD 9HH 9HK 9HL 9HM 9HN 9JH 9JL 9KH 9KL 9KS 9KU 9LH 9LL Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 4/20/40 LO RX-GR08 7/20 RX-GR08 0/0 RX-GR08 4/25/50 HI RX-GR08 PPO PLAN9 25 80/60 500 CBR 7/14 RX-GR08 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 PPO PLAN9 25 80/60 500 CBR 15/25/40 RX-GR08 PPO PLAN9 25 80/60 500 CBR 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 3/20/40/40 RX-GR08 10/10 FLAT C XGR08 PPO PLAN9 25 80/60 500 CBR 4/20/40 T1C H XGR8 4/20/40 T1C L XGR8 10/20 RX-GR08 7/7 C RX-GR08 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 10/20/30 RX-GR08 5/10 RX-GR08 10/20/30 C RX-GR08 4/15/30 T2A H XGR8 4/10/20 RX-GR08 4/15/30 T2A L XGR8 FLEX 15/100A/1000 4/15/30 RX-GR08 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 10/20/35 RX-GR08 10/20/40 RX-GR08 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 469 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit 9LM 9LP 9LV 9MA 9MH 9MI 9ML 9MR 9NH 9NL 9NM 9PH 9PL 9PX 9PY 9QH 9QL 9RH 9RL 9RP 9RX 9TH 9TL 9UH 9UL 9VH 9VL 9VM 9WH 9WI 9WL 9WM 9XH 9XL 9YH 9YL 9ZH 9ZL A10 A38 A88 AAA AAF AAI AAZ AB4 ABA ABN ABZ AC2 Plan / Benefit Description 5/15 C RX-GR08 5/15 RX-GR08 10/20/35 RX-GR08 10/25%/40% RX-GR08 4/20/40 T2B H XGR8 10/20/40 I RX-GR08 4/20/40 T2B L XGR8 10/20/40 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/15/30 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/29/60 P RX-GR08 ALREADY USED 4/20/40 T2B H XGR8 4/20/40 T2B L XGR8 4/15/30 T2A H XGR8 4/15/30 T2A L XGR8 5/15/30 RX-GR08 NO RX 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 5/5 RX-GR08 4/20/40 T1C H XGR8 15/25/40 I RX-GR08 4/20/40 T1C L XGR8 5/7.50 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 STANDARD 10 PLAN 380 PLAN 880 PLAN HMO 10 ADVANTAGE PLAN - FAMILY ADVANTAGE PLAN-INDIVIDUAL HMO 10 COBRA MCC ESS SA PP SH07 HMO 10 MC COMP ESS SA SH07 HMO 10 COBRA ACU/CHIRO/MESSAGE S GOLD 470 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit AC7 ACA ACE ACF ACN ACV ACZ AE7 AEE AEN AER AFA AFE AFF AFR AFS AFZ AG4 AGG AGN AGW AH3 AH4 AH5 AHF AHZ AI2 AI3 AI8 AM1 AM7 AME AMN AMZ AO4 AO9 AOI AOV AOW AOY APF APN APR AQ4 AQ7 AQ8 AQ9 AQE AQN AR1 Plan / Benefit Description 5/15 SANANT C SH06 D467 HMO 10 5/15 SANANT C SH06 EPO BROKER/CONSULTANT FEE 5/15 SANANT C SH06 SV 15-30/250D ATT 07 HMO 10 COBRA 5/10 SANANT CE SH06 D467 5/10 SANANT CE SH06 EPO 5/10 SANANT CE SH06 EMP. RETIRE. SYS. HMO 10 FEDERAL EMPLOYEES-AUSTIN SV 15-30/250D ATT 07 FEDERAL RETIREES PLAN - AT ADMINISTRATIVE SERVICE FEE HMO 10 COBRA ARP MCC ES SA PP SH08 SV 15-30/250D ATT 07 0 SANANT G SH06 ARP MCC ES SA SH08 ALLERGY SERUM 50% ALLERGY SERUM 100% ALLERGY SERUM $10 COPAY SV 15-30/250D ATT 07 CB AUSTIN ISD HIGH OPTION CBR ADVANAGE PLAN-INDIVIDUAL ADVANTAGE PLAN-INDIVIDUAL IND. CONVERSION PLAN 880 TEXAS A&M PLAN 0 SANANT M SH06 D467 0 SANANT M SH06 EPO 0 SANANT M SH06 TEXAS A&M PLAN ARP MCC 1 SA PP SH08 ARP MCC 1 SA PP-PL SH08 ARP MCC 1 SA EP-PL SH08 ARP MCC 1 SA PLUS SH08 ARP MCC 1 SA SH08 ARP MCC 1 SA EP SH08 10/12V 1YR ACU SH07 10/12V 1YR ACU SH08 PREFERRED PLAN MCC 1 SA PP SH07 MCC 1 SA EP-PL SH07 MCC 1 SA PP-PL SH07 MCC 1 SA PLUS SH07 MCC 1 SA EP SH07 MC COMP 1 SA SH07 AMR 2002 $20-$40/$300 471 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit AR2 AR3 AR4 AR5 AR6 AR7 AR8 ARG ART ARV AS0 AS1 AS2 AS3 AS4 AS5 AS6 AS7 ASH AST AT7 ATP ATQ ATU ATV AU4 AU7 AU8 AU9 AUE AUN AUT AWD AWE AZ0 AZ1 AZ2 AZ3 AZ8 AZE AZF AZI AZR AZT AZU B2A B2B B2C B2D B2E Plan / Benefit Description AMR 2002 $20-$40/$300 CBRA AMR 2002 $20-$40/$300 AMR 2002 $20-$40/$300 CBRA AMR 2002 $20-$40/$300 AMR 2002 $20-$40/$300 CBRA AMR 2002 $20-$40/$300 AMR 2002 $20-$40/$300 CBRA SV 15-30/250D ATT 07 CB RESERVED SV 15-30/250D ATT 07 CB ALLERGY SERUM- 100% ALLERGY SERUM ALLERGY SERUM ALLERGY SERUM 80% ALLERGY SERUM $20 COPAY $5 COPAY ALLERGY SERUM SMG $10 COPAY ALLERGY SERUM SG ALLERGY SERUM 90% AUSTIN ISD HIGH OPTION STANDARD PLAN ATW-STD SH-WL07 ATW-PLUS SH-WL07 ATW ENHANCED SH08 ATW-PLUS WL-SH08 ATW-STD WL-SH08 MCC 2 SA PP SH07 MCC 2 SA EP-PL SH07 MCC 2 SA PP-PL SH07 MCC 2 SA PLUS SH07 MCC 2 SA EP SH07 MC COMP 2 SA SH07 UNIVERSITY OF TEXAS SV 15-30/250D ATT 07 SV 15-30/250D ATT 07 CB STANDARD 10 PLAN COBRA ADVANTAGE PLAN-IND.(COBRA) ADVANTAGE PLAN-INDV (COBRA 380 PLAN COBRA 880 PLAN (COBRA) EMP. RETIRE. SYS COBRA ADVANTAGE PLAN-FAM.(COBRA) ADVANTAGE PLAN-INDIVIDUAL PREFERRED PLAN (COBRA) STANDARD PLAN UNIVERS. OF TEXAS (COBRA) RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 472 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit B2F B2G B2H B2J B2P B2R B3A B3B B3C B3D B3E B3F B3G B3H B3J B3P B3R B4A B4B B4C B4D B4E B4F B4G B4H B4J B4P B4R B5A B5B B5C B5D B5E B5F B5G B5H B5J B5P B5R B6A B6B B6C B6D B6E B6F B6G B6H B6J B6P B6R Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVE PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO 473 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit B7A B7B B7C B7D B7E B7F B7G B7H B7J B7P B7R B8A B8B B8C B8D B8E B8F B8G B8H B8J B8P B8R B9A B9B B9C B9D B9E B9F B9G B9H B9J B9P B9R BA1 BA2 BA3 BA4 BAA BAB BAC BAD BB1 BB2 BB3 BB4 BB5 BBH BC5 BC6 BCA Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO BANK AMER $10/250/100% CBR BANK AMER $10/250/100% CBR BANK AMER $10/250/100% CBR BANK AMER $10/250/100% CBR BANK OF AMER $10/$250/100% BANK OF AMER $10/$250/100% BANK OF AMER $10/$250/100% BANK OF AMER $10/$250/100% BELL (SMI/CD/IPMH)PLAN1-7 BELL (SMI/CD/IPMH)PLN348-1 BELL (SMI/CD/IPMH)PLAN1-8 BELL (SMI/CD/IPMH)PLAN1-10 CORNING (SMI/CD/IPMH)189-3 20-30/100A BH 07 SMI/CD/MH PACIFICARE SMI/CD/MH LOCKHEED GM SALARIED 2003 $15/100% 474 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit BCB BCC BCD BCE BCF BCG BCH BCI BCK BCM BE4 BEB BED BEH BET BEU BH1 BH2 BH3 BH6 BH9 BHA BHB BHC BHD BHE BHF BHG BHH BHJ BHK BHL BHM BHN BHP BHQ BHR BHS BHT BHU BHV BHW BHX BHY BKH BN2 BN3 BN4 BN5 BN6 Plan / Benefit Description FIREMANS FUND $20/$40/$250 GM HOURLY 2003 $0/100% BELL HMO/POS $0/100% REED ELSEVIER $10-$20/$250 PEPSI BOTTLING $20/$200 LOCKHEED $20/100% CHEVRON TEXACO $20/100% LOCKHEED $0/100% AT&T $10-$15/$100 SW RESRCH SMI $10-$40-$100 BELL HMO $0/100% COBRA *** OK TO USE *** BELL HMO $0/100% 15-30/250D BH 07 SV 0/100% BELL HELICOP SV 0/100% BELL HELICOP CB BELL 2001 (SMI/CD/IPMH) BOEING NA-HRLY $10 GRP RET BOEING NA-HRLY $10 GRP RET 20/100A LOCKHEED MART MH06 35/240A MH06 NA SMI/CD/MH $10/$20/$100D NA SMI/CD/MH $15/$30/$250D NA SMI/CD/MH $15/$30/$400D NA SMI/CD/MH $20/$40/$250D NA SMI/CD/MH $20/$40/$400D 20-40/250D BH 06 RE SMI/CD/MH $20/$40/$250D 20-40/200A BH 06 NA SMI/CD/MH $5/100% NA SMI/CD/MH $10/100% NA SMI/CD/MH $10/$100 NA SMI/CD/MH $10/$250 NA SMI/CD/MH $15/$100 NA SMI/CD/MH $15/$250 RE SMI/CD/MH $5/100% RE SMI/CD/MH $10/100% RE SMI/CD/MH $15/10% RE SMI/CD/MH $20/100% RE SMI/CD/MH $20/$400 RE SMI/CD/MH $20/20% RE SMI/CD/MH $25/$600 NA SMI/CD/MH $15/100% NA SMI/CD/MH $10/$15/$250 15-20/75A BH 08 BELO $15-$30/$250 BELO $15-$30/$250 COBRA BELO $15-$30/$250 BELO $15-$30/$250 COBRA BELO $15-$30/$250 475 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit BN7 BN8 BN9 BND BNP BNS BNU BO1 BO2 BO3 BO4 BO5 BO6 BO7 BO8 BOP BP1 BP2 BP3 BP4 BP5 BP6 BP7 BP8 BP9 BPA BPB BPC BPD BPE BPF BPG BPH BPJ BPK BPL BPM BPN BPP BPQ BPR BPS BPT BPU BPV BPW BPX BPY BPZ BR2 Plan / Benefit Description BELO $15-$30/$250 COBRA BELO $15-$30/$250 BELO $15-$30/$250 COBRA 15/100A BH07 20 BP AMOCO NON-AARP GR08 20 BP AMOCO NON-AARP GR08 20 BP AMOCO NON-AARP GR08 BOEING HRLY $10/100% BOEING HRLY $10/100% COBRA BOEING HRLY $10/100% BOEING HRLY $10/100% COBRA BOEING HRLY $10/100% BOEING HRLY $10/100% COBRA BOEING HRLY $10/100% BOEING HRLY $10/100% COBRA 20/100% BP AMOCO GR06 20/100% BP AMOCO CC GR06 RESERVED RX PPO RESERVED RX PPO BELL POS $0/$100/70% CBRA RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO BELL POS $0/100%/70% RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 20/100% BP AMOCO GR06 RESERVED PPO RESERVED PPO RESERVED PPO RESERVE PPO RESERVED PPO RESERVED PPO RESERVED RX PPO 476 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit BR3 BR4 BR5 BR6 BR7 BR8 BR9 BS1 BS2 BS3 BSA BSB BSC BSD BSE BSF BSG BSH BSI BSJ BSK BSL BSM BTH BU1 BU2 BU3 BU4 BU5 BU6 BU7 BU8 BU9 BUC BUD BUE BUF BUG BUH BUI BUJ BUK BUL BUM BUN BUO BUP BUQ BUR BUS Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO $10/100% HMO SMALL GRP CBR $10/100% HMO SMALL GRP CBR $10/100% HMO SMALL GRP CBR $10/100% HMO SMALL GROUP $10/100% HMO SMALL GROUP $10/100% HMO SMALL GROUP SG CD/MH $10/$200 SG CD/MH $15/$300 SG CD/MH $20/$400 SG CD/MH $25/$600 SG SMI/CD/MH $20-$40/$250D SG SMI/CD/MH $10/$200 SG CD/MH $15/$300 SG CD/MH $20/$400 SG CD/MH $25/$600 SG CD/MH $20/$40/$250D 20-40/250A BH 08 RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO NA SMI/CD/MH $10/$20/$100 NA SMI/CD/MH $15/$30/$250 NA SMI/CD/MH $15/$30/$400 NA SMI/CD/MH $20/$40/$250 NA SMI/CD/MH $20/$40/$400 477 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit BUT BUU BUV BUW BUX BUY BUZ BVE BVG BVK BVL BVN BVP BVQ BX2 BX3 BX4 BX5 BX6 BX7 BX8 BX9 BXA BXB BXC BXD BXE BXF BXG BXH BXJ BXK BXL BXM BXN BXP BXR BXS BXT BXU BXV BXW BXX BXY BXZ BYA BYB BYC BYD BYE Plan / Benefit Description NA SMI/CD/MH $5/100% NA SMI/CD/MH $10/100% NA SMI/CD/MH $10/$100 NA SMI/CD/MH $10/$250 NA SMI/CD/MH $15/100% NA SMI/CD/MH $15/$100 NA SMI/CD/MH $15/$250 15/100A BOEING VEBA GR07 25/240A BH07 15/100A BOEING VEBA GR07 15 BO-VEBA NON-AARP GR08 15 BO-VEBA NON-AARP GR08 15 BO-VEBA NON-AARP C GR08 15/100A BOEING VEBA GR07 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 478 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit BYF BYG BYH BYJ BYK BYL BYM BYN BYP BYR BYS BZ3 BZ4 BZ5 BZ6 BZ7 BZ8 BZ9 BZA BZB BZC BZD BZE BZG BZH BZJ BZK BZL BZM BZN BZP BZR BZS BZT BZV BZW BZX BZY BZZ C27 C2C C2Z C7A C7E C7F C7G C7H C7J C7K C7L Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO SC 90 ELIGIBILITY ONLY STANDARD $3 MFP STANDARD $3 MFP 5/12V 1YR GR-CH07 10/12V 1YR GR-CH07 10/20V 1YR GR-CH07 10/30V 1YR GR-CH07 15/12V 1YR GR-CH07 15/20V 1YR GR-CH07 0/20V 1YR GR-CH07 15/30V 1YR GR-CH07 479 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit C7M C7P C7S C7U C7W C7Y CBZ CC1 CC2 CC3 CC4 CC5 CC6 CC7 CC8 CC9 CCE CCN CCO CD1 CD2 CD5 CD6 CDD CDJ CDW CDZ CEO CEZ CF1 CF2 CF3 CFA CFD CFE CFF CFZ CG8 CG9 CGG CGI CGL CGP CGR CGS CGT CGU CGV CGX CGZ Plan / Benefit Description 20/12V 1YR GR-CH07 5/10V 1YR GR-CH07 30/12V 1YR GR-CH07 5/20V 1YR GR-CH07 5/30V 1YR GR-CH07 5/40 1YR GR-CH07 HALLIBURTON ENERGY 99 COBR NAT'L 1 $5 CC GR06 NAT'L 2 $10 CC GR06 NAT'L 2A $10 CC GR06 NAT'L 2B $10 CC GR06 NAT'L 2C $20 CC GR06 NAT'L 2D $20 CC GR06 5/15 CORCHR C SH06 D467 NAT'L 3A $15 CC GR06 NAT'L 3B $15 CC GR06 5/15 CORCHR C SH06 EPO 5/15 CORCHR C SH06 5/100% AARP GR08 SECURE HORIZONS SECURE HORIZONS SECURE HORIZONS GP RETIREE SH RETIREE $6 OV STANDARD PLAN CHEM DEP IP $250 OP $20 STANDARD PLAN COBRA KMART 1999 COBRA 15/30V CH 07 15/200/1200 THR 2000 COBRA RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO LOCKHEED PLAN M P1-99 COBR 10/20V CH 07 15/20V CH 07 CAREGIVER-SH GOLD CAREGIVER-SH INDIV CAREGIVER LITE SH06 CAREGIVER PROGRAM CAREGIVER-RESPITE SH-06 CAREGIVER PROGRAM CAREGIVER STD CG-SH08 CAREGIVER-RESPITE CG-SH08 CAREGIVER CG-GR08 CAREGIVER ENHANCED LOCKHEED SALARIED 2000 COB 480 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit CH1 CH2 CH5 CH6 CHA CHB CHC CHD CHQ CHU CHW CHZ CIZ CJZ CKZ CMZ CN4 CP2 CP3 CP4 CP9 CPA CQ1 CQZ CR1 CR2 CR3 CR4 CR5 CR6 CRG CRR CRX CRY CRZ CS1 CS2 CS6 CT1 CT2 CT3 CT4 CT5 CTZ CU1 CU3 CU4 CUE CUN CV1 Plan / Benefit Description SECURE HORIZONS - CORRIDOR SH B-ONLY - CORRIDOR SECURE HORIZON GP RETIREE SH RETIREE $6 OV CHIROCARE $0/10 VISITS TX CHIROCARE $5/10 VISITS TX CHIROCARE $10/10 VISITS TX CHIROCARE $15/10 VISITS TX FEDS 20/20V ACU/CHIRO 05 10/12V 1YR SH-CH07 10/12V 1YR SH-CH08 LOCKHEED HOURLY 2000 COBRA IND PROD 20/20%/2000 COBRA MILLER 1999 COBRA TEXAS A&M 2000 COBRA THOMSON CORP 2000 COBRA 5/30V CH 07 CHIRO $10/10 VISIT CFW CHIRO $5/10 VISIT CFW CHIRO $0COPAY/10 VISIT FEDS 20/20V ACU/CHIRO 07 RESERVED PFFS 10/30V CH 07 TEXAS UTILITIES 2000 COBRA HRS SENIOR CHIRO $10 SELF HRS SENIOR CHIRO $5/10 OV GRP RET CHIRO $5/12VISITS GRP RET CHIRO $10/12VISITS GRP RET CHIRO $15/12VISITS GRP RET CHIRO $20/12VISITS CUSTOM PPO 10/12V GR-CH07 RESERVED FOR RX PPO RESERVED FOR RX PPO IND PROD 15/20%/2000 COBRA SECURE HORIZONS-CORRIDOR SECURE HORIZONS ONLY SH RETIREE $6 OV NAT'L CHIRO $10/20 VISITS NAT'L CHIRO $15/20 VISITS NAT'L CHIRO $15/30 VISITS NAT'L CHIRO $5/30 VISITS NAT'L CHIRO $10/30 VISITS CORNING FLEX COBRA 15/10V CH 07 10/10V CH 07 MCC CC PP SH07 MCC CC EP SH07 MC COMP CC SH07 CHEVRON TEX $20/100% 481 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit CV2 CV3 CV4 CV5 CV6 CV7 CV8 CX4 CXW CXY D00 D1C D1D D1F D1H D1K D1L D1M D1P D1T D1V D1W D1X D1Y D1Z D20 D2D D2H D2L D2M D2N D2P D2U D2X D2Y D30 D3D D4D D5D D6V D8A D8B D8D D8E D8P DA1 DA2 DAE DAF DAG Plan / Benefit Description CHEVRON TEX $20/100% COBRA CHEVRON TEX $20/100% CHEVRON TEX $20/100% COBRA CHEVRON TEX $20/100% CHEVRON TEX $20/100% COBRA CHEVRON TEX $20/100% CHEVRON TEX $20/100% COBRA ARP MCC CC PP SH08 ARP MCC CC SH08 ARP MCC CC EP SH08 DURABLE MED EQUIP $0 STANDARD 5 CUSTOM STANDARD 5 CUSTOM STANDARD 5 CUSTOM STANDARD 5 POS COBRA STANDARD 5 CUSTOM STANDARD 5 POS STANDARD 5 POS STANDARD 5 POS STANDARD 5 CUSTOM COBRA STANDARD 5 CUSTOM -COBRA STANDARD 5 CUSTOM -COBRA STANDARD 5 POS COBRA STANDARD 5 POS COBRA STANDARD 5 CUSTOM -COBRA DURABLE MED EQUIP 20% DOD FEDS $10 CUSTOM 1-00 $5 POS COBRA $5 POS $5 POS $5 POS $5 POS $5 POS COBRA $5 POS COBRA $5 POS COBRA DURABLE MED EQUIP $1000 YR DOD FEDS $10 CUSTOM 1-00 DOD FEDS $10 CUSTOM 1-00 DOD FEDS $10 CUSTOM 1-00 DENTAL - VISION GR06 DELUXE OPTION DN-SH08 PREVENTIVE DN-SH08 $0 467 DN-SH08 $20 469 DN-SH08 EC PREVENT 250 1YR DN-SH08 SH DALLAS BASIC SH DALLAS PRT B ONLY 10-20/200A DART GR07 10-20/200A DART GR07 10-20/200A DART CC GR07 482 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit DBA DBB DC7 DCB DCE DCN DDB DDD DDW DE7 DEC DED DEE DEK DEN DEV DEW DEZ DGN DH1 DH2 DH5 DH6 DHK DHL DHM DHN DIR DKK DKV DL4 DLD DLE DLN DM6 DM7 DME DMN DN2 DN3 DNA DNE DNF DNT DNY DP1 DP6 DPA DPB DPC Plan / Benefit Description 100%/70% DISCOUNT GR-DN07 10-20 DART NON-AARP GR08 5/25 DALLAS C SH06 D467 10-20 DART NON-AARP GR08 5/25 DALLAS C SH06 EPO 5/25 DALLAS C SH06 10-20 DART NON-AARP C GR08 STANDARD 5 PLAN STANDARD 5 PLAN COBRA 5/10 DALLAS CE SH06 D467 ERS-STATE OF TEXAS SAN ANT ERS-STATE OF TEXAS DALLAS 5/10 DALLAS CE SH06 EPO ERS-STATE OF TEXAS (HSTN) 5/10 DALLAS CE SH06 ERS-STATE OF TEXAS COBRA ERS-STATE OF TEXAS COBRA ERS-STATE OF TEXAS COBRA 0 DALLAS G SH06 SECURE HORIZONS - DALLAS SH-DALLAS-B ONLY SECURE HORIZON GP RETIREE SH RETIREE $6 OV FEDS DOD EMPLOYEES 2001 FEDS DOD EMPLOYEES 2001 FEDS DOD EMPLOYEES 2001 FEDS DOD EMPLOYEES 2001 DUMMY-USED FOR VRU CODING STANDARD 10-KROGER STANDARD 10 KROGER-COBRA MCC 1 DFW PP SH07 MCC 1 DFW DELUXE SH07 MCC 1 DFW EP SH07 MC COMP 1 DFW SH07 $0 467 SH-DN06 5/10 DALLAS M SH06 D467 5/10 DALLAS M SH06 EPO 5/10 DALLAS M SH06 RESERVED PPO GRP RET DEN RESERVED PPO GRP RET DEN PREVENTIVE SH-DN07 EVERCARE $5 SH-DN07 EVERCARE $0 SH-DN07 PREVENTIVE DENTAL PLAN DELUXE OPTION SH-DN07 DEPENDENT LIFE BENE $5 PREVENTIVE SH-DN06 SAME SEX DOMESTIC PARTNER OPPOSITE DOMESTIC PARTNER DOMESTIC PARTNER SAME/OPPO 483 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit DQ6 DR1 DR2 DR3 DR4 DR5 DR6 DRD DRR DRW DS1 DS2 DSR DT2 DTC DTD DTO DTP DTR DTW DTX DU4 DUD DUE DUN DV4 DVW DVX DVY DX4 DXD DXE DXN DY4 DYW DYX DYY EC0 EC1 EC2 EC3 EC7 ECF ECG ECI ECK ENC ENZ ER2 ER3 Plan / Benefit Description $20 469 SH-DN06 DRUG REHABILITATION DRUG REHABILITATION (50%) DRUG REHABILITATION - UT DRUG REHABILITATION - ERS SH GRP RET $5/100% 2001 SH GRP RET $6/100% 2001 EMP RETIREE SYSTEM PLAN 10-20/200A DERP GR07 EMP RETIREE SYS PLAN COBRA DALLAS AREA-SH INDIVIDUAL DALLAS-SH INDIV.PRT B ONLY 10-20/200A DERP GR07 TX SH OPT DENTAL DENTAL - FHP TEXAS A&M PLAN DENTAL ONLY (INDEMNITY) PREVENTIVE DENTAL 10-20/200A DERP GR07 TEXAS A&M PLAN (COBRA) DENTAL ONLY (INDEMNITY) MCC 2 DFW PP SH07 MCC 2 DFW DELUXE SH07 MCC 2 DFW EP SH07 MC COMP 2 DFW SH07 ARP MCC 1 DFW PP SH08 ARP MCC 1 DFW SH08 ARP MCC 1 DFW DLX SH08 ARP MCC 1 DFW EP SH08 MCC ESS DFW PP SH07 MCC ESS DFW DELUXE SH07 MCC ESS DFW EP SH07 MC COMP ESS DFW SH07 ARP MCC ES DFW PP SH08 ARP MCC ES DFW SH08 ARP MCC ES DFW DLX SH08 ARP MCC ES DFW EP SH08 EVERCARE DH DAL SH07 EVERCARE DH CC SH07 STAND 10 - NO REFRACTION STAND 10 - NO REFRACTION EVERCARE IH DAL SH07 EVERCARE DH SA SH07 EVERCARE IH SA SH07 EARLY CHILDHOOD INTERVENTN EVERCARE BH SA SH07 SONY STANDARD PLAN SONY STANDARD PLAN (COBRA) EMP. RET. SYS. PLAN STATE EMP RET SYS PLAN 484 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit ERS ESA ESB ESC ESD ESE ESZ ETD ETE ETF ETG ETJ ETK ETM ETP EUO EVO EWO EXO EYO EZ2 EZ3 EZO EZS F01 F02 F03 F04 F05 F06 F07 F08 F09 F10 F11 F12 F13 F14 F15 F16 F17 F18 F19 F1A F1B F1C F1H F1K F1L F1M Plan / Benefit Description EMP. RETIRE. SYS. PLAN $10F/$25NF $12F/$27NF $15F/$30NF $6F/$21NF $5F/$10NF EMP RET SYS PLAN (COBRA) EVERCARE DFW DH SH08 EVERCARE SA DH SH08 EVERCARE SA IH SH08 EVERCARE CC DH SH08 EVERCARE DFW IH SH08 EVERCARE DFW MH SH08 EVERCARE SA MH SH08 EVERCARE CC MH SH08 EVERCARE DFW DH-D SH08 EVERCARE SA DH-D SH08 EVERCARE CC DH-D SH08 EVERCARE DFW MH-D SH08 EVERCARE CC MH-D SH08 STAND 1- NO REFRAC.(COBRA) STND 10-NO REFRAC. (COBRA) EVERCARE SA MH-D SH08 EMP. RETIRE. SYS. COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO STANDARD $10 POS PLAN STANDARD $10 POS PLAN CBRA CUSTOM STANDARD 10 PLAN STANDARD 10 POS COBRA FEHB STANDARD 10 POS STANDARD 10 POS 485 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit F1P F1X F1Y F1Z F20 F21 F22 F23 F24 F25 F26 F27 F28 F29 F2H F2K F2L F2M F2N F2P F2U F2V F2X F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F3A F3B F3Y F40 F41 F42 F43 F44 F45 F46 F47 F48 F49 F4A F4B F50 F51 Plan / Benefit Description STANDARD 10 POS STANDARD 10 POS COBRA STANDARD 10 POS COBRA CUSTOM STANDARD 10 - COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO $10 POS COBRA STANDARD 10 MFP $10 POS $10 POS $10 POS $10 POS $10 POS COBRA STANDARD 10 MFP COBRA $10 POS COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO PIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO STANDARD $10 POS PLAN SMAL STANDARD $10 POS SMALL CBR $10 POS COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO STANDARD $10 POS PLAN SMAL STANDARD $10 POS SMALL CBR LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO 486 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit F52 F53 F54 F55 F56 F57 F58 F59 F5C F5D F5R F60 F6C F6D F7A F7B F7C F7D F8C F8D FA2 FA3 FA4 FA5 FA6 FA7 FA8 FA9 FB6 FBB FBD FBE FBF FBH FBJ FC8 FC9 FCA FCB FCE FCF FCI FCJ FCL FCM FCN FDA FDB FDC FDD Plan / Benefit Description LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO IMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO POS 10/90/70 POS 10/90/70 COBRA RESERVED LG HMO $15/90% LIMITED FEE SCHEDULE PPO POS 10/90/70 POS 10/90/70 COBRA STANDARD $10 POS PLAN STANDARD $10 POS PLAN COB POS 10/90/70 POS 10/90/70 COBRA POS 10/90/70 POS 10/90/70 COBRA AT&T NATL $10-$15/$100 AT&T NATL $10-$15/$100 CBR AT&T NATL $10-$15/$100 AT&T NATL $10-$15/$100 CBR AT&T NATL $10-$15/$100 AT&T NATL $10-$15/$100 CBR AT&T NATL $10-$15/$100 AT&T NATL $10-$15/$100 CBR SV 20-40/250D FEDS 06 FITNESS BENEFIT SH06 SV 25/240A FIDELITY 07 SV 25/240A FIDELITY 07 SV 25/240A FIDELITY 07 FEDS 2003 I/P BH/MH 100% FEDS 2004 I/P MH/CD RESERVED FOR RX PPO RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX SV 20-40/400D FEDS SV 20-40/400D FEDS ERS STATE OF TEXAS STANDARD 10 PLAN 487 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit FDE FDF FDG FDH FDI FDJ FDK FDL FDM FDN FDO FDP FDR FDS FDT FDU FDV FDW FDX FDZ FE1 FE2 FE3 FE4 FEC FED FEK FEV FEW FEZ FF1 FF2 FF3 FF4 FF5 FF6 FF7 FF8 FFC FFD FFE FFF FFH FFK FFL FFM FG1 FG3 FG4 FGE Plan / Benefit Description ERS STATE OF TEXAS ERS STATE OF TEXAS ERS - STATE OF TEXAS ERS - STATE OF TEXAS ERS - STATE OF TEXAS ERS - STATE OF TEXAS ERS STATE OF TEXAS ERS STATE OF TEXAS COBRA ERS-STATE OF TX. ERS-STATE OF TX COBRA ERS-STATE OF TX ERS-STATE OF TX COBRA ERS - STATE OF TEXAS COBRA ERS - STATE OF TEXAS COBRA ERS - STATE OF TEXAS COBRA ERS - STATE OF TEXAS COBRA ERS STATE OF TEXAS COBRA STANDARD 10 PLAN COBRA ERS STATE OF TEXAS COBRA ERS STATE OF TEXAS COBRA FEDERAL EMPLOYEES PLAN FEDERAL EMPLOYEES PLAN FEDERAL EMPLOYEES 1991 FEDERAL EMPLOYEE PLAN 1992 ERS-STATE OF TEXAS ERS-STATE OF TEXAS ERS-STATE OF TEXAS ERS-STATE OF TEXAS COBRA ERS-STATE OF TEXAS ERS-STATE OF TEXAS COBRA TX FF $20-$40/$250 TX FF $20-$40/$250 COBRA TX FF $20$40/$250 TX FF $20-$40/$250 COBRA TX FF $20-$40/$250 TX FF $20-$40/$250 COBRA TX FF $20-$40/$250 TX FF $20-$40/$250 COBRA FEDERAL EMPLOYEE PLAN FEDERAL EMPLOYEE PLAN SV 25/240A FIDELITY 07 ADMINISTRATIVE RETENTION FEDERAL EMPLOYEE PLAN FEHB PLAN EFF 1-99 FEHB PLAN EFF 1-99 FEHB PLAN EFF 1-99 GM RETIREE $10/100% GM RETIREE $10/100% GM RETIREE $10/100% SV 25/240A FIDELITY 07 CB 488 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit FGK FGL FGM FGN FH1 FH2 FH3 FH6 FHE FHK FHL FHM FHN FHP FHQ FHR FHS FHU FHV FHW FHZ FID FJF FL1 FL2 FL3 FL4 FL5 FL6 FL7 FL8 FLA FLB FLC FLD FLE FLF FLG FLH FMH FN1 FN2 FN3 FN4 FN5 FN6 FN7 FN8 FNA FNB Plan / Benefit Description FEDS $10 CUSTOM EFF 1-00 CEDS $10 CUSTOM EFF 1-00 FEDS $10 CUSTOM EFF 1-00 FEDS $10 CUSTOM EFF 1-00 HMO IVF RIDER IN-VITRO ART SUPP RIDER $150 COPAY ART SUPP RIDER $100 COPAY SV 20-40/250D FEDS 06 SV 25/240A FIDELITY 07 CB FEDS 2001 FEDS 2001 FEDS 2001 FEDS 2001 FEDS 2003 FEDS 2003 FEDS 2003 FEDS 2003 FEDS 2004 FEDS 2004 FEDS 2004 FEDS 2004 FEDS DENTAL INDEMNITY 2001 SV 25/240A FIDELITY 07 CB TX LG HMO $15/90% COBRA TX LG HMO $15/90% COBRA TX LG HMO $15/90% COBRA TX LG HMO $15/90% COBRA TX LG HMO $25/$600 COBRA TX LG HMO $25/$600 COBRA TX LG HMO $25/$600 COBRA TX LG HMO $25/$600 COBRA TX LG HMO $15/90% TX LG HMO $15/90% TX LG HMO $15/90% TX LG HMO $15/90% TX LG HMO $25/$600 TX LG HMO $25/$600 TX LG HMO $25/$600 TX LG HMO $25/$600 I/P MH 100% FEDS FNF $10 - $15 /$250 FNF $10 - $15 /$250 COBRA FNF $10 - $15 / $250 FNF $10 - $15 / $250 COBRA FNF $10 - $15 / $250 FNF $10 - $15 / $250 COBRA FNF $10 - $15 / $250 FNF $10 - $15 / $250 COBRA SV 10-15/250A FIDELITY SV 10-15/250A FIDELITY CB 489 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit FND FNE FNF FNG FNH FNI FR1 FR9 FRA FRC FRS FS1 FS2 FS3 FS4 FS5 FS6 FS7 FS8 FSA FSB FSC FSD FSE FSF FSG FSH FSL FTB FTL FVB FWR FXD FZ1 FZ2 FZ3 G00 GBB GBZ GH1 GH2 GH5 GH6 GM0 GM1 GM2 GM4 GM5 GM6 GM7 Plan / Benefit Description SV 10-15/250A FIDELITY SV 10-15/250A FIDELITY CB SV 10-15/250A FIDELITY SV 10-15/250A FIDELITY CB SV 10-15/250A FIDELITY SV 10-15/250A FIDELITY CB FEDERAL RETIREES PLAN RESERVED LG HMO $15/90% CB RISK CHARGE - AGGREGATE RESERVED LG HMO $15/90% RISK CHARGE - SPECIFIC TX SG HMO $15/$300 COBRA TX SG HMO $15/$300 COBRA TX SG HMO $15/$300 COBRA TX SG HMO $15/$300 COBRA TX SG HMO $25/$600 COBRA TX SG HMO $25/$600 COBRA TX SG HMO $25/$600 COBRA TX SG HMO $25/$600 COBRA TX SG HMO $15/$300 TX SG HMO $15/$300 TX SG HMO $15/$300 TX SG HMO $15/$300 TX SG HMO $25/$600 TX SG HMO $25/$600 TX SG HMO $25/$600 TX SG HMO $25/$600 SILVER SNEAKER SH/GR-WL07 SV 20-40/250D FEDS 08 SILVER SNEAKER SH/GR-WL08 SV 20-40/250D FEDS 08 CITY FT WORTH RETIREES SV 25/240A FIDELITY 07 CB ADVANTAGE PLAN-FAM.(COBRA) ADVANT. PLAN FAM (COBRA 2) ADVANT. PLAN-FAM (COBRA 3) I/P MENTAL 100% BELLBASIC 2002 $20/$350 BELLBASIC 2002 $20/$350 CB SH STANDARD - GALVESTON SH B ONLY - GALVESTON SECURE HORIZON GP RETIREE SH RETIREE $6 OV GM SAL 2003 $15/100% COBRA GM SAL 2003 $15/100% GM SAL 2003 $15/100% COBRA GM HOURLY - $0/100% COBRA GM SAL 2003 $15/100% GM SAL 2003 $15/100% COBRA GM SAL 2003 $15/100% 490 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit GM8 GM9 GMA GMB GMD GMS GMZ GR1 GR3 GR4 GS4 GSD H01 H02 H03 H04 H05 H06 H07 H08 H09 H0C H0Z H10 H11 H12 H13 H14 H15 H16 H17 H18 H19 H1V H1Z H20 H21 H22 H23 H24 H25 H26 H27 H28 H29 H2C H2X H2Z H30 H31 Plan / Benefit Description GM SAL 2003 $15/100% COBRA GM SAL 2003 $15/100% GM RETIREE SALARIED 2003 GM RETIREE SALARIED 2003 GM HOURLY - $0/100% GM SAL 2002 $10/100% GM SAL 2002 $10/100% COBRA GM RET.#601602 $5/100% GM RET.#601602 $5/100% GM RET.#601602 $5/100% GM SALARIED- $5/100% COBRA GM SALARIED - $5/100% HRS IND.RX 5G/20BR UNLM/NF VISION CARE BENEFIT PPO FAMILY PLANING BENEFIT PPO 24/HOUR HEALTH INFO PPO RESERVED FOR PPO PRODUCT MENTAL NON-SMI PPO 90/70 RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT MENTAL NON-SMI PPO 80/60 10/200/1000 AMERICAN A COB SFLEX 9601 99 COBRA STANDARD 10 PLAN $5G/10B HRS RET.5G/10BR UNLM/NOFRM HRS RET 5G/20BR 1000 BR LM RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO SFLEX 10/200/1000 COBRA STANDARD PLAN COBRA PLAN 20 $10G/10B RESERVED FOR PPO $10G/20B $5G/20B RESERVED FOR PPO RESERVED FOR PPO $5G/10B $7G/15B RESERVED FOR PPO ALCON 2000 COBRA SFLEX 10/300/1200 COBRA PLAN 20 COBRA 10G/20B/35N RESERVED FOR PPO 491 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit H32 H33 H34 H35 H36 H37 H38 H39 H3C H3X H3Z H40 H41 H42 H43 H44 H45 H46 H47 H48 H49 H4C H4Z H50 H51 H52 H53 H54 H55 H56 H57 H58 H59 H5C H5Z H60 H61 H62 H63 H64 H65 H66 H67 H68 H69 H6C H6P H6Z H70 H71 Plan / Benefit Description 5G/20B/35N 7G/15B/25N HRS RET.5G/10BR UNLM/FORM RESERVED FOR PPO $10G/20B $5G/20B 380 PLAN $5G/10B BELL PLAN AAA 2000 COBRA SFLEX 15/100/1000 COBRA 380 PLAN COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO $10G/15B RESERVED FOR PPO $5G/5B RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO BELL NB BASIC 2000 COBRA SFLEX 15/200/1000 COBRA $3G/3B RESERVED FOR PPO $2G/2B $5G/5B RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO CFW PLAN M 2000 COBRA SFLEX 15/300/1200 COBRA RESERVED FOR PPO $5G/5B RESERVED FOR PPO $10G/15B RESERVED FOR PPO RESERVED FOR PPO 20% COPAY RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO CFW HIGH OPTION 2000 COBRA 15-25/100A GR06 SFLEX 15/400/1500 COBRA RESERVED FOR PPO RESERVED FOR PPO 492 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit H72 H73 H74 H75 H76 H77 H78 H79 H7C H7Z H80 H81 H82 H83 H84 H85 H86 H87 H88 H89 H8A H8B H8C H8D H8E H8F H8G H8J H8K H8P H8R H8T H8V H8X H8Z H90 H91 H92 H93 H94 H95 H96 H97 H98 H99 H9C H9Z HA1 HA2 HA3 Plan / Benefit Description RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 10G/15B/30N RESERVED FOR PPO CFW LOW OPTION 2000 COBRA SFLEX 20/300/1200 COBRA $20G/$40B RESERVED FOR PPO RESERVED FOR PPO $5G/20B RESERVED FOR PPO $5G/10B/25N RESERVED FOR PPO $10G/$20B/$35N POS 880 PLAN $5G/$10B/$20N POS 0/500A 3YRS PL HA-SH08 0/1300A 3YRS DX HA-SH08 GM HOURLY 2000 COBRA 0/800A 3YRS DX HA-SH08 25/400A 3YRS HA-SH08 25/900A 3YRS PL HA-SH08 0/800A 3YRS HA-SH08 5/400A 3YRS HA-SH08 0/600A 2YRS HA-SH08 15-25/100A AARP GR08 3/20/40/40 RX-GR08 15-25/100A AARP GR08 15-25/100A AARP C GR08 SFLEX 20/400/1500 COBRA 880 PLAN COBRA $7G/$15B/$25N POS $10G/$20B $5G/$20B/$35N POS $10G/$20B/$35N POS $7G/$15B/$25N POS $3G/$3B POS RESERVED FOR PPO RESERVED RESERVED FOR PPO RESERVED FOR PPO GM SALARIED 99 COBRA SFLEX 25/600/2000 98 COBRA TEXAS A&M PLAN HEARING AID - $1000 MAX HEARING AID-UNLIMITED MAX 493 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit HA4 HA5 HAB HAD HAJ HAN HAO HAR HAS HAX HAZ HB1 HB2 HB3 HB4 HB5 HB6 HB7 HB8 HB9 HBA HBB HBC HBD HBE HBF HBG HBH HBI HBJ HBK HBL HBM HBN HBO HBP HBQ HBR HBS HBT HBU HBV HBW HBX HBY HBZ HC0 HC1 HC2 HC3 Plan / Benefit Description HEARING AID - $1,120 MAX HEARING AID BENEFIT $5.00 HARRIS INDIV. PART B ONLY HEARING AID DISCOUNT HEARING AID $500 EVERY 3YR 300A/24M GR-HA07 HEARING AID BENEFIT 23RRIS SH INDIVIDUAL PLAN SECURE GOLD SCREEN + AID SFLEX 25/600/2000 99 COBRA TEXAS A&M PLAN DOMESTIC PARTNERSHIP PPO MENTAL NON-SMI PPO 80 MENTAL NON-SMI 80/50 PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO FLEX PREF 99 COBRA 10/200/1000 AMERICAN AIR ALCON 2000 BELL PLAN AAA 2000 BELL NB HARRIS BASIC 2000 494 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit HC4 HC5 HC6 HC7 HC8 HC9 HCA HCB HCC HCD HCE HCF HCG HCH HCI HCJ HCK HCL HCM HCN HCO HCP HCQ HCR HCS HCT HCZ HD1 HD6 HDD HDE HDW HDZ HE1 HE2 HEZ HF4 HF6 HFZ HGZ HH0 HH1 HH2 HH3 HH4 HH5 HH6 HH7 HH8 HH9 Plan / Benefit Description CFW PLAN M 2000 CFW HIGH OPTION 2000 CFW LOW OPTION 2000 GM HOURLY 2000 GM SALARIED 99 HALLIBURTON ENERGY 99 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO KMART 1999 15/200/1200 THR CSTM 2000 LOCKHEED PLAN M P1-99 INDIV PRODUCT 20/20%/2000 LOCKHEED SALARIED 2000 LOCKHEED HOURLY 2000 MILLER 1999 TEXAS A&M 2000 THOMSON CORP 2000 RESERVED FOR PPO INDIV PRODUCT 15/20%/2000 TEXAS UTILITIES 2000 CORNING FLEX 10/300/1200 RESERVED FOR PPO RESERVED FOR PPO FLEX P10 99 COBRA HARRIS DENTAL $7 CO-PAY 5/400A 3 YRS SH-HA06 380 PLAN 300A 2YRS HA-GR08 380 PLAN COBRA FLEX 1-10 99 COBRA HARRIS HEARING AID UNLIM HARRIS HEARNG AID $500 LIM FLEX PLAN 1 99 COBRA FEDERAL EMPLOYEE PLAN 1994 25/400A 3 YRS SH-HA06 FLEX 10/0/800 COBRA FLEX 10/100/1000 COBRA HEARING AID 1 EA MAX 500EA SH STANDARD - HOUSTON SH B-ONLY HOUSTON HEARING AID 500 EA EAR HEARING AID 1EA EAR NO MAX SECURE HORIZON GP RETIREE SH RETIREE $6 OV HEARING AID 500 PER EAR HEARING AID 500 EACH EAR HEARING AID 1,000 EA EAR 495 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit HHB HHC HHE HHZ HIZ HJZ HKZ HL8 HLZ HM1 HM2 HM4 HM6 HMC HMD HME HMF HMG HMJ HMK HML HMP HMZ HN1 HN2 HNZ HOA HOE HOI HP1 HP2 HP3 HP4 HP5 HP6 HP7 HP8 HP9 HPE HPZ HQZ HR1 HR2 HR3 HR5 HR6 HR7 HR8 HRB HRD Plan / Benefit Description RESERVED FOR PPO HEARING AID - $900 PER EAR 500A 3YRS HA-GR08 FLEX 10/200/1000 COBRA FLEX 10/250/1000 COBRA FLEX 10/300/1200 COBRA FLEX 15/100A/1000 COBRA 400A 3YRS 0PREM HA-GR08 FLEX 15/100/1000 COBRA $5G/10B 5G/10B/20N $5G/5B HRS RET.5G/5BR UNLIM NOFRM FLEX 15/100/1000 FLEX 15/200/1000 FLEX 15/300/1200 FLEX 15/400/1500 FLEX 20/200/1000 FLEX 20/300/1200 FLEX 20/400/1500 FLEX 25/600/2000 IND CONV FLEX 25/600/2000 FLEX 15/200/1000 COBRA HOUSTON AREA-SH INDIVIDUAL HOUSTON-SH INDV.PRT B ONLY FLEX 15/300/1200 COBRA RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED HEARING PFFS 5G/20B $1000B MAX HRS RX RET.5G/10BR UNLM/NF HRS RX RET.5G/20BR UNLM/FM HRS RX RET.5G/20BR UNLM/NF HRS RX RET.5G/10BR UNLM/FM HRS RX RET.5G/10BR UNLM/FM HRS RX RET.5G/10BR UNLM/NF HRS RX RET.5G/5BR UNLM/NF HRS RX RET.5G/20BR $1000MX RESERVED PFFS FLEX 15/400/1500 COBRA FLEX 20/200/1000 COBRA DALLAS-SH INDIVIDUAL DALLAS-SH INDV.PRT B ONLY EMP. RET. SYS. - HOUSTON SH GRP RET $5/100% 2001 SH GRP RET $6/100% 2001 HRING AID $500 ALLOWANCE HRING AID $300 ALLOWANCE 0/500A 3YRS SH-HA07 0/800A 3YRS DX SH-HA07 496 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit HRE HRF HRG HRJ HRK HRL HRP HRR HRY HRZ HS0 HS1 HS2 HS3 HS4 HS5 HS6 HS7 HS8 HS9 HSA HSB HSC HSD HSE HSF HSG HSJ HSL HSM HSN HST HSZ HTC HTZ HUZ HVZ HWZ HX6 HZ5 I01 I02 I03 I04 I05 I06 I07 I08 I09 I0A Plan / Benefit Description 5/400A 3YRS SH-HA07 25/400A 3YRS SH-HA07 SH INDIV. HEARING 0/800A 3YRS SH-HA07 0/600A 2YRS SH-HA07 25/900A 3YRS PL SH-HA07 0/500A 3YRS PL SH-HA07 300A GR-HA07 0/1300A 3YRS DX SH-HA07 FLEX 20/300/1200 COBRA SFLEX 9601 99 STANDARD PLAN SFLEX 10/200/1000 SFLEX 10/300/1200 SFLEX 15/100/1000 STANDARD 5 PLAN SFLEX 15/200/1000 SFLEX 15/300/1200 SFLEX 15/400/1500 SFLEX 20/300/1200 HARRS RET $7OV/$50ER/$25UR HARRIS RET.5 OV/50 ER/25UR HARRIS RET.$5OV/$25ER/$5UR SFLEX 20/400/1500 HARRIS RETIREE IBM SFLEX 25/600/2000 98 SFLEX 25/600/2000 99 HARRIS RET. JC PENNEY HARRIS RET $5OV/$25ER/$5UR HARRIS RET.MITCHELL ENERGY HARRIS RET.SBC HARRIS RET $0 OV/$0ER & UR EMP. RET. SYS. COBRA 500A 2YRS HA-GR08 STANDARD 10 PLAN COBRA FLEX 20/400/1500 COBRA FLEX 25/600/2000 IND CV CB FLEX 25/600/2000 COBRA 15-25/100A CORP CHRIS GR06 STANDARD 5 PLAN INDEMNITY PLAN INDEMNITY PLAN INDEMNITY PLAN INDEMNITY PLAN INDEMNITY PLAN HOSPITAL INDEMNITY PLAN HOSPITAL INDEMNITY PLAN HOSPITAL INDEMNITY PLAN SMALL GROUP PPO SMALL GROUP PPO 497 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit I0B I0C I0D I0E I0F I0G I0H I0I I0J I0K I0L I0M I0N I0P I0Q I0R I0S I0T I0U I0V I0W I0Z I11 I12 I13 I14 I16 I17 I18 I19 I1A I1B I1C I1D I1J I1K I1L I1M I1P I1Z I21 I22 I23 I24 I26 I27 I28 I29 I2A I2B Plan / Benefit Description SMALL GROUP PPO PREV. PRIM. CARE-INDEMNITY PREV. PRIM. CARE-INDEMNITY PREV. PRIM. CARE-INDEMNITY BASIC COVERAGE/INDEMNITY BASIC COVERAGE/INDEMNITY BASIC COVERAGE/INDEMNITY STD HEALTH BENEFIT/IND STD. HEALTH BENEFIT/IND STD. HEALTH BENEFIT/IND. CATASTROPHIC/INDEMNITY CATASTROPHIC/INDEMNITY CATASTROPHIC/INDEMNITY 80/60 SMALL GRP PPO 1-99 80/60 PPO SMALL GRP 1-99 80/60 PPO SMALL GRP 1-99 DUMMY 80/60 SM GRP PPO-PHCS NTWK 80/60 SM GRP PPO-PHCS NTWK 80/60 SM GRP PPO-PHCS NTWK 80/60 SM GRP PPO-PHCS NTWK IDY 500/80-20% 4000/8000CB LARGE GRP PPO PLAN 1 CBRA LARGE GRP PPO PLAN 1 CBRA LARGE GRP PPO PLAN 1 CBRA LARGE GROUP PPO PLAN 1 COB PPO PLAN1 LG/CBR-PHCS NTWK PPO PLAN1 LG/CBRA-PHCS NET PPO PLAN1 LG/CBRA-PHCS NET PPO PLAN1 LG/CBRA-PHCS NTW LARGE GROUP PPO PLAN 1 LARGE GROUP PPO PLAN 1 LARGE GROUP PPO PLAN 1 LARGE GROUP PPO PLAN 1 PPO PLAN 1 LG-PHCS NETWORK PPO PLAN 1 LG-PHCS NETWORK PPO PLAN 1 LG-PHCS NETWORK PPO PLAN 1 LG-PHCS NETWORK NATIONAL PPO (SAN ANTONIO) NATIONAL PPO/COBRA SAN ANT LARGE GRP PPO PLAN 2 CBRA LARGE GRP PPO PLAN 2 CBRA LARGE GRP PPO PLAN 2 CBRA LARGE GROUP PPO PLAN 2 COB PPO PLAN2 LG/CBRA-PHCS NET PPO PLAN2 LG/CBRA-PHCS NET PI2MPLAN2 LG/CBRA-PHCS NET PPO PLAN2 LG/CBRA-PHCS NET LARGE GROUP PPO PLAN 2 LARGE GROUP PPO PLAN 2 498 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit I2C I2D I2J I2K I2L I2M I31 I32 I33 I34 I36 I37 I38 I39 I3A I3B I3C I3D I3H I3J I3K I3L I3M I3P I3Z I41 I42 I43 I44 I46 I47 I48 I49 I4A I4B I4C I4D I4H I4J I4K I4L I4M I4P I4Z I50 I51 I52 I53 I54 I56 Plan / Benefit Description LARGE GROUP PPO PLAN 2 LARGE GROUP PPO PLAN 2 PPO PLAN 2 LG-PHCS NETWORK PPO PLAN 2 LG-PHCS NETWORK PPO PLAN 2 LG-PHCS NETWORK PPO PLAN 2 LG-PHCS NETWORK LARGE GRP PPO PLAN 3 CBRA LARGE GRP PPO PLAN 3 CBRA LARGE GRP PPO PLAN 3 CBRA LARGE GROUP PPO PLAN 3 COB PPO PLAN3 LG/CBRA-PHCS NET PPO PLAN3 LG/CBRA-PHCS NET PPO PLAN3 LG/CBRA-PHCS NET PPO PLAN3 LG/CBRA-PHCS NET LARGE GROUP PPO PLAN 3 LARGE GROUP PPO PLAN 3 LARGE GROUP PPO PLAN 3 LARGE GROUP PPO PLAN 3 UNIDEN IDY COBRA PPO PLAN 3 LG-PHCS NETWORK PPO PLAN 3 LG-PHCS NETWORK PPO PLAN 3 LG-PHCS NETWORK PPO PLAN 3 LG-PHCS NETWORK NATIONAL PPO (HOUSTON) NATIONAL PPO/COBRA HOUSTON LARGE GRP PPO PLAN 4 CBRA LARGE GRP PPO PLAN 4 CBRA LARGE GRP PPO PLAN 4 CBRA LARGE GROUP PPO PLAN 4 COB PPO PLAN4 LG/CBRA-PHCS NET PPO PLAN4 LG/CBRA-PHCS NET PPO PLAN4 LG/CBRA-PHCS NET PPO PLAN4 LG/CBRA-PHCS NET LARGE GROUP PPO PLAN 4 LARGE GROUP PPO PLAN 4 LARGE GROUP PPO PLAN 4 LARGE GROUP PPO PLAN 4 GREENVILLE ALTER COBRA PPO PLAN 4 LG-PHCS NETWORK PPO PLAN 4 LG-PHCS NETWORK PPO PLAN 4 LG-PHCS NETWORK PPO PLAN 4 LG-PHCS NETWORK NATIONAL PPO DALLAS NATIONAL PPO/COBRA DALLAS INDEMNTIY SAN ANTONIO LARGE GRP PPO PLAN 5 CBRA LARGE GRP PPO PLAN 5 CBRA LARGE GRP PPO PLAN 5 LARGE GROUP PPO PLAN 5 COB PPO PLAN5 LG/CBRA-PHCS NET 499 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit I57 I58 I59 I5A I5B I5C I5D I5H I5J I5K I5L I5M I5P I5X I5Z I60 I61 I62 I63 I64 I6A I6B I6C I6D I6H I6P I6X I6Z I70 I71 I72 I73 I74 I7A I7B I7C I7D I7H I7P I7X I7Z I81 I82 I83 I8C I8D I8P I8X IA0 IA1 Plan / Benefit Description PPO PLAN5 LG/CBRA-PHCS NET PPO PLAN5 LG/CBRA-PHCS NET PPO PLAN5 LG/CBRA-PHCS NET LARGE GROUP PPO PLAN 5 LARGE GROUP PPO PLAN 5 LARGE GROUP PPO PLAN 5 LARGE GROUP PPO PLAN 5 DELEON ISD ALTERNATE COBRA PPO PLAN 5 LG-PHCS NETWORK PPO PLAN 5 LG-PHCS NETWORK PPO PLAN 5 LG-PHCS NETWORK PPO PLAN 5 LG-PHCS NETWORK NATIONAL PPO- PHCS NETWORK NATIONAL PPO-PHCS NTWK COB INDEMNITY SAN ANTONIO COB INDEMNITY-HOUSTON LARGE GRP IND PLAN 6 CBRA LARGE GRP IND PLAN 6 CBRA LARGE GRP IND PLAN 6 CBRA LARGE GRP IND PLAN 6 COBRA LARGE GRP INDEMNITY PLAN 6 LARGE GRP INDEMNITY PLAN 6 LARGE GRP INDEMNITY PLAN 6 LARGE GRP INDEMNITY PLAN 6 COMMERCE ISD ALT COBRA NATIONAL PPO- PHCS NETWORK NATIONAL PPO-PHCS NTWK COB INDEMNITY HOUSTON COBRA INDEMNITY DALLAS LARGE GRP IND PLAN 7 CBRA LARGE GRP IND PLAN 7 CBRA LARGE GRP IND PLAN 7 CBRA LARGE GRP IND PLAN 7 COBRA LARGE GRP INDEMNITY PLAN 7 LARGE GRP INDEMNITY PLAN 7 LARGE GRP INDEMNITY PLAN 7 LARGE GRP INDEMNITY PLAN 7 ROYSE CITY ISD ALT COBRA NATIONAL PPO- PHCS NETWORK NATIONAL PPO-PHCS NTWK COB INDEMNITY DALLAS COBRA IND. CONVERSION PLAN 880 INDIVIDUAL CONVERSION (2) INDIVIDUAL CONVERSION (3) PPO PLAN 8 20 80/60 500 PPO PLAN 8 20 80/60 500 NATIONAL PPO- PHCS NETWORK NATIONAL PPO-PHCS NTWK COB PPO PLAN10 15 80/60 250 PPO PLAN1 15 90/70 250 500 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit IA2 IA3 IA4 IA5 IA6 IA7 IA8 IA9 IAZ IB0 IB1 IB2 IB3 IB4 IB5 IB6 IB7 IB8 IB9 IBZ IC0 IC1 IC2 IC3 IC4 IC5 IC6 IC7 IC8 IC9 ICA ICB ICZ ID0 ID1 ID2 ID3 ID4 ID5 ID6 ID7 ID8 ID9 IDN IDZ IE1 IF1 IH0 IH1 IH2 Plan / Benefit Description PPO PLAN2 20 90/70 250 PPO PLAN 3 10 90/70 250 PPO PLAN 4 20 90/70 500 PPO PLAN 5 15 80/60 500 PPO PLAN 6 20 90/70 500 PPO PLAN 7 10 80/60 500 PPO PLAN 8 20 80/60 500 PPO PLAN 9 25 80/60 500 COLSCH-1097 (IDY) COBRA PPO PLAN10 15 80/60 250 PPO PLAN1 15 90/70 250 PPO PLAN2 20 90/70 250 PPO PLAN 3 10 90/70 250 PPO PLAN 4 20 90/70 500 PPO PLAN 5 15 80/60 500 PPO PLAN 6 20 90/70 500 PPO PLAN 7 10 80/60 500 PPO PLAN 8 20 80/60 500 PPO PLAN 9 25 80/60 500 TCU IDY 500/80-20% 98 CBRA PPO PLAN10 15 80/60 250 PPO PLAN 1 15 90/70 250 PPO PLAN 2 20 90/70 250 PPO PLAN 3 10 90/70 250 PPO PLAN 4 20 90/70 500 PPO PLAN 5 15 80/60 500 PPO PLAN 6 20 90/70 500 PPO PLAN 7 10 80/60 500 INDIVIDUAL CONVERSION (3) PPO PLAN 9 25 80/60 500 CUSTOM PPO DUMMY OK TO USE INDEMNITY INDIV CONV COBRA PPO PLAN10 15 80/60 250 PPO PLAN 1 15 90/70 250 PPO PLAN 2 20 90/70 250 PPO PLAN 3 10 90/70 250 PPO PLAN 4 20 90/70 500 PPO PLAN 5 15 80/60 500 PPO PLAN 6 20 90/70 500 PPO PLAN 7 10 80/60 500 INDIVIDUAL CONVERSION PPO PLAN 9 25 80/60 500 INDEMNITY NATIONAL PPO INDEMNITY NATIONAL PPO COB PPO PLAN11 20 80/60 250 IN VITRO FERTILIZATION IDY 500/80-20% 4000/8000 COLSCH-1097 (IDY) TCU IDY 500/80-20% 98 501 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit IH3 IH4 IH5 IH6 IH7 IH8 IHC IHN IHZ IJ1 IK1 IK2 IK3 IK4 IK5 IK6 IK7 IK8 IL1 IM0 IM1 IM2 IM3 IM4 IM5 IM6 IM7 IM8 IM9 IMB IMC IMD IME IMF IMG IMH IMJ IMK IML IMM IMN IMO IMQ IMR IMS IMT IMU IMV IMZ IN1 Plan / Benefit Description UNIDEN IDY GREENVILLE ALTER DELEON ISD ALTERNATE COMMERCE ISD ALT ROYSE CITY ISD ALT INDIVIDUAL CONVERSION INDEMNITY INDIV CONVERSION INDEMNITY NATIONAL PPO INDEMNITY NATIONAL PPO COB PPO PLAN11 20 80/60 250 INDEMNITY CUSTOM INDEMNITY CUSTOM COBRA INDEMNITY CUSTOM INDEMNITY CUSTOM COBRA INDEMNITY CUSTOM INDEMNITY CUSTOM COBRA INDEMNITY CUSTOM INDEMNITY CUSTOM COBRA PPO PLAN11 20 80/60 250 IP MNTL HLTH SFLEX 110-3 IP MNTL HLTH SFLEX 119-003 IP MNTL HLTH SFLEX 103-4 IP MNTL HLTH SFLEX 99-3 IP MNTL HLTH SFLEX 107-4 IP MNTL HLTH SFLEX 98-3 IP MNTL HTLH SFLEX 102-4 IP MNTL HLTH SFLEX 101-4 IP MNTL HLTH SFLEX 114-2 IP MNTL HLTH SFLEX 114-003 IP MNTL HLTH KMART 116-003 IP MNTL HLTH 15/200 188-5 IP MNTL HLTH PLN M 009-004 IP MNTL HLTH LOCKSAL 4-011 IP MNTL HLTH LOCKHR 004-12 IP MNTL HLTH MILLER 14-004 IP MNTL HLTH TXA&M 19-006 IP MNTL HLTH THOMSON 349-1 IP MNTL HLTH TXUT 183-003 IP MNTL HLTH IND PRO 262-4 IP MNTL HLTH IND PRO 341-1 IP MNTL HLTH POSFLEX 193-4 IP MNTL HLTH POSFLEX 189-3 IP MNTL HLTH POSFLEX 108-3 IP MNTL HLTH POSFLEX 109-3 IP MNTL HLTH POSFLEX 219-3 IP MNTL HLTH POSFLEX 106-4 IP MNTL HLTH POSFLEX 100-3 IP MNTL HLTH POSFLEX 123-3 IP MNTL HLTH SFLEX 92-003 IND PLAN 1 80%/250/2000 502 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit IN2 IN3 IN4 IN5 IN6 IN7 IN8 IO9 IOP IOQ IOR IOS IR1 IS1 IS2 IS3 IS4 IS5 IS6 IS7 IS8 ISN ISZ IX1 IX2 IX3 IX4 IX5 IX6 IX7 IX8 IX9 IXP IXQ IXR IY1 IY2 IY3 IY4 IY5 IY6 IY7 IY8 IZ1 IZ2 IZ3 IZ4 IZ5 IZ6 IZ7 Plan / Benefit Description IND PLAN 2 80%/500/4000 IND PLAN 1 80%/250/2000 IND PLAN 2 80%/500/4000 IND PLAN 1 80%/250/2000 IND PLAN 2 80%/500/4000 IND PLAN 1 80%/250/2000 IND PLAN 2 80%/500/4000 HOSPITAL INDEMNITY PLAN BASIC COVERAGE/INDEMNITY STD HEALTH BENEFIT/IND CATASTROPHIC/INDEMNITY 80/60 SMALL GRP PPO 1-99 PPO PLAN11 20 80/60 250 INDEMNITY SG 80% 300 2000 INDEMNITY SG 80% 500 4000 INDEMNITY SG 80% 300 2000 INDEMNITY SG 80% 500 4000 INDEMNITY SG 80% 300 2000 INDEMNITY SG 80% 500 4000 INDEMNITY SG 80% 300 2000 INDEMNITY SG 80% 500 4000 INDEMNITY NATIONAL PPO INDEMNITY NATIONAL PPO COB IND PLAN 1 80%/250/2000 CB IND PLAN 2 80%/500/4000 CB IND PLAN 1 80%/250/2000 CB IND PLAN 2 80%/500/4000 CB IND PLAN 1 80%/250/2000 CB IND PLAN 2 80%/500/4000 CB IND PLAN 1 80%/250/2000 CB IND PLAN 2 80%/500/4000 CB HOSPITAL INDEMNITY COBRA BASIC COVERAGE/IND. COBRA STD HEALTH BENEFIT/IND COB CATASTROPHIC/INDEMNITY COB IND S GRP 80% 300 2000 CBR IND S GRP 80% 500 4000 CBR IND S GRP 80% 300 2000 CBR IND S GRP 80% 500 4000 CBR IND S GRP 80% 300 2000 CBR IND S GRP 80% 500 4000 CBR IND S GRP 80% 300 2000 CBR IND S GRP 80% 500 4000 CBR INDEMNITY PLAN COBRA INDEMNITY PLAN COBRA ADVANTAGE PLAN-INDV(COBRA) INDEMNITY PLAN INDEMNITY PLAN (COBRA) HOSPITAL INDEMNITY PLAN HOSPITAL INDEMNITY PLAN 503 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit IZ8 IZ9 IZA IZB IZC IZD IZE IZF IZG IZH IZI IZJ IZK IZL IZM IZN IZP IZQ IZR IZS IZT IZU IZV IZW J1C J1Z JDD JDW JKR JR3 JR4 JR6 KA2 KA3 KA4 KA5 KA6 KA7 KA8 KA9 KB2 KB3 KB4 KB5 KB6 KB7 KB8 KB9 KD2 KD3 Plan / Benefit Description HOSPITAL INDEMNITY PLAN SMALL GROUP PPO-COBRA SMALL GROUP PPO-COBRA SMALL GROUP PPO-COBRA PREV. PRIM. CARE-IND.COBRA PREV. PRIM. CARE-IND COBRA PREV. PRIM. CARE-IND COBRA BASIC COVERAGE/INDEM-COBRA BASIC COVERAGE/INDEM-COBRA BASIC COVERAGE/INDEM-COBRA STD. HEALTH BEN./IND COBRA STD. HEALTH BEN./IND COBRA STD. HEALTH BEN./IND COBRA CATASTROPHIC-INDEMNITY/COB CATASTROPHIC/INDEMNITY-COB CATASTROPHIC/INDEMNITY-COB 80/60 PPO SMALL GRP 1-99CB 80/60 PPO SMALL GRP 1-99CB 80/60 PPO SMALL GRP 1-99CB 80/60 SMALL GRP PPO COBRA 80/60 SM GRP PPO/CBRA-PHCS 80/60 SM GRP PPO/CBRA-PHCS 80/60 SM GRP PPO/CBRA-PHCS 80/60 SM GRP PPO/CBRA-PHCS 880 MFP PLAN 880 MFP PLAN -COBRA 880 PLAN 880 PLAN COBRA 5-25/300A JKR W/D SH05 JCPENNY GRP RET $6/100% JCPENNY GRP RET $6/100% JCPENNY GRP RET $6/100% RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 504 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit KD4 KD5 KD6 KD7 KD8 KD9 KE2 KE3 KE4 KE5 KE6 KE7 KE8 KE9 KF2 KF3 KF4 KF5 KF6 KF7 KF8 KF9 KG2 KG3 KG4 KG5 KG6 KG7 KG8 KG9 KH8 KH9 KJ2 KJ3 KJ4 KJ5 KJ6 KJ7 KJ8 KJ9 KL2 KL3 KL4 KL5 KL6 KL7 KL8 KL9 KM2 KM3 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 505 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit KM4 KM5 KM6 KM7 KM8 KM9 KR2 KR3 KR4 KR5 KR6 KR7 KR8 KR9 KRJ KS2 KS3 KS4 KS5 KS6 KS7 KS8 KS9 KT2 KT3 KT4 KT5 KT6 KT7 KT8 KT9 KU2 KU3 KU4 KU5 KU6 KU7 KU8 KU9 KV2 KV3 KV4 KV5 KV6 KV7 KV8 KV9 KW2 KW3 KW4 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 5-25/300A JKR SH05 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 506 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit KW5 KW6 KW7 KW8 KW9 KX2 KX3 KX4 KX5 KX6 KX7 KX8 KX9 KY2 KY3 KY4 KY5 KY6 KY7 KY8 KY9 L01 L02 L03 L1A L1B L1C L1D L1E L1F L2C L2D L2E L2F L31 L32 L33 L3A L3B L3C L3D L3E L3F L41 L42 L43 L4A L4B L4C L4D Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO LIFE COVERAGE LIFE COVERAGE PLAN LIFE COVERAGE STANDARD $20 POS PLAN STANDARD $20 POS PLAN CBRA POS 20/90/70 POS 20/90/70 COBRA POS 20/90/60 POS 20/90/60 COBRA POS 20/90/70 POS 20/90/70 COBRA POS 20/90/60 POS 20/90/60 COBRA LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN STANDARD $20 POS SMALL GRP STANDARD $20 POS SMALL CBR POS 20/90/70 POS 20/90/70 COBRA POS 20/90/60 POS 20/90/60 COBRA LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN STANDARD POS $20 SMALL GRP STANDARD $20 POS SMALL CBR POS 20/90/70 POS 20/90/70 COBRA 507 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit L4E L4F L50 L51 L52 L53 L54 L55 L56 L57 L58 L59 L5A L5B L5C L5D L60 L61 L62 L63 L64 L65 L66 L67 L68 L69 L6A L6B L6C L6D L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L7A L7B L7C L7D L8A L8B L8C L8D L9A L9B Plan / Benefit Description POS 20/90/60 POS 20/90/60 COBRA LIFE W/O SEAT LRG SAN ANT LIFE W/O SEAT LRG SAN ANT LIFE W/O SEAT LRG SAN ANT LIFE W/O SEAT LRG SAN ANT LIFE W/SEAT LRG SAN ANT LIFE W/SEAT LRG SAN ANT LIFE W/SEAT LRG SAN ANT LIFE W/SEAT LRG SAN ANT LIFE W/O SEAT SMALL SAN AN LIFE W/SEAT SMALL SAN ANT $20 POS $20 POS COBRA POS 20/80/60 POS 20/80/60 COBRA LIFE W/O SEAT LRG HOUSTON LIFE W/O SEAT LRG HOUSTON LIFE W/O SEAT LRG SAN ANT LIFE W/O SEAT LRG SAN ANT LIFE W/SEAT LRG HOUSTON LIFE W/SEAT LRG HOUSTON LIFE W/SEAT LRG HOUSTON LIFE W/SEAT LRG HOUSTON LIFE W/O SEAT SMALL HOUST LIFE W/SEAT SMALL HOUSTON $20 POS $20 POS COBRA POS 20/80/60 POS 20/80/60 COBRA LIFE W/O SEAT LRG DALLAS LIFE W/O SEAT LRG DALLAS LIFE W/O SEAT LRG DALLAS LIFE W/O SEAT LRG DALLAS LIFE W/SEAT LRG DALLAS LIFE W/SEAT LRG DALLAS LIFE W/SEAT LRG DALLAS LIFE W/SEAT LRG DALLAS LIFE W/O SEAT SMALL DALLAS LIFE W/SEAT SMALL DALLAS $20 POS $20 POS COBRA POS 20/80/60 POS 20/80/60 COBRA $20 POS $20 POS COBRA POS 20/80/60 POS 20/80/60 COBRA STANDARD $20 POS PLAN STANDARD $20 POS PLAN COB 508 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit LA4 LAD LBC LBH LC1 LC2 LC3 LC4 LC5 LC6 LC7 LC8 LC9 LCA LCB LCC LDC LDF LEB LEC LF1 LF3 LF4 LFC LFD LFG LG6 LH1 LH2 LH3 LH4 LH5 LH6 LH7 LH8 LH9 LHA LHB LHC LHD LHE LHF LHG LHH LHI LHZ LID LIE LIR LJC Plan / Benefit Description 20-30/250A LOKHEED GR06 20-30/250A LOKHEED GR06 SV 15-20/75A LHMRTN 08 SV 15/100A LOCKHEED 07 CB LIFE W/SEAT MID/LG SAN ANT LIFE W/SEAT MID/LG SAN ANT LIFE W/SEAT MID/LG SAN ANT LIFE W/SEAT MID/LG HOUSTON LIFE W/SEAT MID/LG HOUSTON LIFE W/SEAT MID/LG HOUSTON LIFE W/SEAT MID/LG DALLAS LIFE W/SEAT MID/LG DALLAS LIFE W/SEAT MID/LG DALLAS LIFE W/SEAT MID/LG AUSTIN LIFE W/SEAT MID/LG AUSTIN LIFE W/SEAT MID/LARGE AUST SV 15-20/75A LHMRTN 08 CB SV 15/100A LOCKHEED 07 SV 20-40/250A LHMRTN 08 SV 20-40/250A LHMRTN 08 LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE COVERAGE PLAN SV 15/100A LOCKHEED 07 SV 15/100A LOCKHEED 07 SV 15/100A LOCKHEED 07 CB 20-30/250A LOKHEED CC GR06 LIFE LOCKHEED $20/100% LOCKHEED $20/100% COBRA LOCKHEED $20/100% LOCKHEED $20/100% COBRA LOCKHEED $20/100% LOCKHEED $20/100% COBRA LOCKHEED $20/100% LOCKHEED $20/100% COBRA LOCKHEED HOURLY 2001 SV $10/100% LOCKHEED L SV $10/100% LOCKHEED L CB SV $10/100% LOCKHEED L SV $10/100% LOCKHEED L CB SV $10/100% LOCKHEED L SV $10/100% LOCKHEED L CB SV $10/100% LOCKHEED L SV $10/100% LOCKHEED L CB LOCKHEED HOURLY 2001 COBRA DENTAL - SECURE GOLD LOW INCOME EDUCATION LOW INCOME EDUCATION 05 SV 20-40/250A LHMRTN 08 CB 509 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit LK1 LK2 LK3 LK4 LK5 LK6 LK7 LK8 LKC LL3 LLA LLB LLC LLD LLE LLF LLG LLH LM1 LM2 LM3 LM4 LMB LMC LMD LME LMH LMJ LMS LMX LMZ LOC LOG LOK LOL LON LOP LPW LQB LQC LQS LQW LR1 LR3 LR4 LRS LRW LS1 LS2 LS3 Plan / Benefit Description SV 20/100% LOCKHEED SV 20/100% LOCKHEED CB SV 20/100% LOCKHEED SV 20/100% LOCKHEED CB SV 20/100% LOCKHEED SV 20/100% LOCKHEED CB SV 20/100% LOCKHEED SV 20/100% LOCKHEED CB SV 20-40/250A LHMRTN 08 LIFELINK SV 10/100% LOCKHEED SV 10/100% LOCKHEED CB SV 10/100% LOCKHEED SV 10/100% LOCKHEED CB SV 10/100% LOCKHEED SV 10/100% LOCKHEED CB SV 10/100% LOCKHEED SV 10/100% LOCKHEED CB LIFE W/SEAT MID/LG SAN ANT LIFE W/SEAT MID/LG HOUSTON LIFE W/SEAT MID/LG DALLAS LIFE W/SEAT MID/LG AUSTIN SV 20-40/250A LHMRTN 08 CB SV 20-30/100A 06 SV 20-30/100A 06 CB SV 20-30/100A 06 SV 20-30/100A 06 CB SV 20-30/100A 06 SV 20-30/100A 06 CB SV 20-30/100A 06 SV 20-30/100A 06 CB 20-30/250A LOKHEED CC GR07 20-30/250A LOKHEED GR07 20-30/250A LOKHEED GR07 20-30 LOKHEED NON-AARP GR8 20-30 LOKHEED NON-AARP GR8 20-30 LOKHEED NON-AARP GR8 SV 20-30/100A LKHEED 07 SV 20-40/250A LHMRTN 08 SV 20-40/250A LHMRTN 08 CB SV 15-20/75A LHMRTN 08 SV 20-30/100A LKHEED 07 CB LOCKHEED RET600018 $5/100% LOCKHEED RET600018 $5/100% LOCKHEED RET600018 $5/100% SV 15-20/75A LHMRTN 08 CB SV 20-30/100A LKHEED 07 LIFE W/SEAT SMALL SAN ANT LIFE W/SEAT SMALL HOUSTON LIFE W/SEAT SMALL DALLAS 510 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit LS4 LSS LSW LT1 LT3 LT4 LTC LTD LTG LTM LTS LTW LUB LUC LUE LUW LV1 LV3 LV4 LVW LWB LWW M00 M0A M1S M1W M1Y M70 M80 M90 MA2 MA4 MAB MAC MAD MDD MDW MH0 MH1 MH2 MH3 MH4 MH5 MH6 MH7 MH8 MH9 MHA MHB MHD Plan / Benefit Description LIFE W/SEAT SMALL AUSTIN SV 15-20/75A LHMRTN 08 SV 20-30/100A LKHEED 07 CB LOCKHEED RET#18021$5/100% LOCKHEED RET#18021$5/100% LOCKHEED RET#18021$5/100% SV 15-20/75A LHMRTN 08 RESERVED FOR PPO LIFE SV 15/100A LOCKHEED 07 CB RESERVED FOR LIFETIME MAX SV 15-20/75A LHMRTN 08 CB SV 20-30/100A LKHEED 07 SV 15/100A LOCKHEED 07 SV 15-20/75A LHMRTN 08 CB SV 15/100A LOCKHEED 07 CB SV 20-30/100A LKHEED 07 CB LOCKHEED RET#18057$5/100% LOCKHEED RET#18057$5/100% LOCKHEED RET#18057$5/100% SV 20-30/100A LKHEED 07 SV 20-40/250A LHMRTN 08 CB SV 20-30/100A LKHEED 07 CB INPATIENT MENTAL (100%) IP MH $500 ADMIT MERCER 2070 PLAN (OPT) 2070 PLAN (OPT) 2070 PLAN (OPT) INPATIENT MENTAL (70%) INPATIENT MENTAL (80%) INPATIENT MENTAL (90%) MOTOROLA $5/100% COBRA MOTOROLA $5/100% COBRA MOTOROLA $5/100% IP MENTAL HEALTH 100% MOTOROLA $5/100% PLAN 20 PLAN 20 COBRA MENTAL HEALTH $250 MENTAL HEALTH O/P $5 OV MENTAL HEALTH O/P $10 OV MENTAL HEALTH O/P $15 OV MENTAL HEALTH $200 MENTAL HEALTH $300 MENTAL HEALTH $400 IP MNTL HLTH FLEX 97-003 MENTAL HEALTH $600 IP MNTL HLTH FLEX 118-003 MENTAL HEALTH $150 I/P MNTL HLTH - CUSTOM GM IP MNTL HLTH FLEX 172-004 511 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit MHE MHF MHG MHH MHI MHJ MHK MHL MHM MHQ MHR MHT MHU MHV MHW MHX MHY MI0 MI1 MI4 MI5 MI6 MI7 MI8 MI9 MIB MIC MID MIE MIF MIG MIH MIJ MIK MIL MS0 MS2 MS6 MS7 MS9 MSB MSE MSF MSG MSI MSJ MSK MSN MSP MSQ Plan / Benefit Description IP MNTL HLTH FLEX 225-003 IP MNTL HLTH FLEX 193-004 IP MNTL HLTH FLEX 321-002 IP MNTL HLTH FLEX 111-004 IP MNTL HLTH FLEX 335-002 IP MNTLH HLTH FLEX 189-003 IP MNTL HLTH FLEX 104-003 IP MNTL HLTH FLEX 218-003 IP MNTL HLTH FLEX 112-003 IP MNTL HLTH FLEX 108-003 IP MNTL HLTH FLEX 109-003 IP MNTL HLTH FLEX 219-003 IP MNTL HLTH FLEX 106-004 IP MNTL HLTH FLEX 100-003 IP MNTL HLTH FLEX 308-001 IP MNTL HLTH FLEX 123-003 IP MNTL HLTH AAIR 339-001 SMI $10OV/200IP AAIR 339-1 SMI $20OV/300IP ALCN 345-2 SMI $0OV/0IP CWF-M 120-3 SMI $5OV/0IP CWF-HI 121-3 SMI $10OV/20%IP CWFL 122-3 SMI $0OV/0IP GM-HOUR 320-2 SMI $0OV/0IP GM-SALA 342-1 SMI $10OV/250IP HLBN 187-3 SMI $10OV/400IP KMRT 116-3 SMI $15OV/200IP CUST 188-5 SMI $0OV/0IP LM-PLAN M 9-4 SMI $10OV/0IP LM SAL 4-11 SMI $10OV/0IP LM-HOUR 4-12 SMI $5OV/0IP MILLER 14-4 SMI $10OV/20%IP TX AM 19-6 SMI $0OV/0IP THOMSON 349-1 INDEPENDENT $25 PLAN SMI $15OV/20%IP TXUT 183-3 SMI $15OV/20%IP FLEX 97-3 SMI $10OV/20%IP FLEX 118-3 SMI $10OV/0IP FLEX 172-4 SMI $3OV/0IP FLEX 225-3 SMI $10OV/0IP FLEX 193-4 SMI $10OV/100IP FLEX 321-2 SMI $10OV/200IP FLEX 111-4 SMI $10OV/250IP FLEX 335-2 SMI $10OV/300IP FLEX 189-3 SMI $15OV/100IP FLEX 104-3 SMI $15OV/100IP FLEX 218-3 SMI $15OV/200IP FLEX 112-3 SMI $15OV/300IP FLEX 108-3 SMI $15OV/400IP FLEX 109-3 SMI $20OV/200IP FLEX 219-3 512 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit MSR MSS MST MSU MT0 MT3 MT4 MT5 MT6 MT7 MT8 MTK MTM N01 N02 N03 N04 N05 N06 N07 N08 N09 N0F N0R N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N1A N1B N1C N1D N1E N1F N1G N1R N20 N21 N22 N23 N24 N25 N26 N27 Plan / Benefit Description SMI $20OV/300IP FLEX 106-4 SMI $20OV/400IP FLEX 100-3 SMI $25OV/600IP FLEX 308-1 SMI $25OV/600IP FLEX 123-3 IP MNTL HLTH ALCON 345-002 IP MNTL HLTH CFW 120-003 IP MNTL HLTH CFWHG121-003 IP MNTL HLTH CFWLO 122-003 IP MNTL HLTH GMHR 320-002 IP MNTL HLTH GMSAL 342-001 IP MNTL HLTH HALLIB 187-3 10/5V 1YR MSG THRPY SH07 10/5V 1YR MSG THRPY SH08 INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS SV 15-30/250A NAT'L CB NAT'L $20/$40/$400 DAY CBR INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 2B $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET NAT'L $10/$20/$100 COBRA INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS 513 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit N28 N29 N2F N2R N30 N3A N3B N3C N3D N3E N3F N3G N3R N4A N4B N4C N4D N4E N4F N4G N4R N5F N5R N6F N6R N7F N7R N8F N8R N9F N9R NA1 NA2 NA3 NA4 NA5 NA6 NA8 NAA NAB NAC NAD NAE NAF NAG NAH NAI NAK NAL NAN Plan / Benefit Description INDEMNITY PLANS INDEMNITY PLANS SV 20-40/400D NAT'L CB NAT'L $15/$30/$250 COBRA INDEMNITY PLANS NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 2B $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET NAT'L $15/$30/$400 COBRA NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 2B $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLAN 3B $15 GRP RET NAT'L $20/$40/$250 DAY CBR SV 15-30/250A NAT'L CB NAT'L $20/$40/$400 DAY CBR SV 15-30/400A NAT'L CB NAT'L $10/$20/$100 COBRA SV 20-40/250D NAT'L CB NAT'L $15/$30/$250 COBRA SV 20-40/400D NAT'L CB NAT'L $15/$30/$400 COBRA SV 10-20/100A NAT'L CB NAT'L $20/$40/$250 DAY CBR PHS NATL $5/100% CBRA PHS NATL $10/100% CBRA PHS NATL $10/$100 COBRA PHS NATL $10/$250 COBRA PHS NATL $15/$250 COBRA PHS NATL $15/100% COBRA PHS NATL $15/$100 COBRA PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100 PHS NATL $10/$250 PHS NATL $15/$250 PHS NATL $15/100% NATL POS $10/100%/70% NATL POS $10/90%/70% PHS NATL $15/$100 NATL POS $15/80%/60% NATL POS $15/$150/70% NATL POS $10/100%/70% 514 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit NAO NAQ NAR NC1 NC2 NC3 NCA NCB NCC ND1 ND2 ND3 ND4 ND5 ND6 ND8 NDA NDB NDC NDD NDE NDF NDG NE1 NE2 NE3 NE4 NE5 NE6 NE7 NEA NEB NEC NED NEE NEF NEG NF0 NF1 NF2 NF3 NF4 NF5 NF6 NF7 NF8 NF9 NFA NFB NFC Plan / Benefit Description NATL POS $10/90%/70% NATL POS $15/80%/60% NATL POS $15/$150/70% $10/$0 MERCER PLAN 1 COBRA $10/$0 MERCER PLAN 2 COBRA $15/$500 MERCER PLAN3 CBRA $10/$0 MERCER PLAN 1 $15/$0 MERCER PLAN 2 $15/$500 MERCER PLAN3 PHS NATL $5/100% COBRA PHS NATL $10/100% COBRA PHS NATL $10/$100 COBRA PHS NATL $10/$250 COBRA PHS NATL $15/$250 COBRA PHS NATL $15/100% COBRA PHS NATL $15/$100 COBRA PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100 PHS NATL $10/$250 PHS NATL $15/$250 PHS NATL $15/100% PHS NATL $15/$100 SV 5/100% NATL CB SV 10/100% NATL CB SV 15/100% NATL CB SV 10/100A NATL CB SV 10/250A NATL CB SV 15/250A NATL CB SV 15/100A NATL CB SV 5/100% NATL SV 10/100% NATL SV 15/100% NATL SV 10/100A NATL SV 10/250A NATL SV 15/250A NATL SV 15/100A NATL SV 15-30/250A NAT'L CB $10/$0 MERCER PLAN 1 COBRA $15/$0 MERCER PLAN 2 COBRA $15/$500 MERCER PLAN 3 COB SV 10-20/100A NAT'L CB SV 15-30/250A NAT'L CB SV 15-30/400A NAT'L CB SV 20-40/250D NAT'L CB SV 20-40/400D NAT'L CB SV 10-20/100A NAT'L CB $10/$0 MERCER PLAN 1 $15/$0 MERCER PLAN 2 $15/$500 MERCER PLAN 3 515 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit NFD NFE NFF NFG NFH NFI NFJ NFK NFL NFM NFN NFO NFP NFQ NFR NFS NFT NFU NFV NFW NFY NFZ NGA NGB NGC NGD NGX NGZ NHX NHZ NJ1 NJ2 NJ3 NJ4 NJ5 NJ6 NJ7 NJA NJB NJC NJD NJE NJF NJG NK1 NK2 NK3 NK4 NK5 NK6 Plan / Benefit Description SV 10-20/100A NAT'L SV 15-30/250A NAT'L SV 15-30/400A NAT'L SV 20-40/250D NAT'L SV 20-40/400D NAT'L SV 10-20/100A NAT'L SV 15-30/250A NAT'L SV 15-30/400A NAT'L SV 20-40/250D NAT'L SV 20-40/400D NAT'L SV 10-20/100A NAT'L SV 15-30/250A NAT'L SV 15-30/400A NAT'L SV 20-40/250D NAT'L SV 20-40/400D NAT'L SV 10-20/100A NAT'L SV 15-30/250A NAT'L SV 15-30/400A NAT'L SV 20-40/250D NAT'L SV 20-40/400D NAT'L SV 15-30/400A NAT'L CB SV 10-20/100A NAT'L CB NAT'L PLN 2C $20 GRP RET NAT'L PLN 2C $20 GRP RET NAT'L PLN 2D $20 GRP RET NAT'L PLN 2D $20 GRP RET NATL POS $10/100%/70% CBRA NATL POS $10/100%/70% CBRA NATL POS $10/90%/70% COBRA NATL POS $10/90%/70% COBRA SV 5/100% NATL CB SV 10/100% NATL CB SV 15/100% NATL CB SV 10/100A NATL CB SV 10/250A NATL CB SV 15/250A NATL CB SV 15/100A NATL CB SV 5/100% NATL SV 10/100% NATL SV 15/100% NATL SV 10/100A NATL SV 10/250A NATL SV 15/250A NATL SV 15/100A NATL SV 5/100% NATL CB SV 10/100% NATL CB SV 15/100% NATL CB SV 10/100A NATL CB SV 10/250A NATL CB SV 15/250A NATL CB 516 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit NK7 NKA NKB NKC NKD NKE NKF NKG NKX NKZ NL8 NLF NLG NLX NLZ NN1 NN2 NN3 NN4 NN5 NN6 NN7 NNA NNB NNC NND NNE NNF NNG NNX NNZ NOX NOZ NPG NPH NPK NPL NPN NPO NPQ NPR NQX NQZ NR0 NR1 NR2 NR3 NR4 NR5 NR6 Plan / Benefit Description SV 15/100A NATL CB SV 5/100% NATL SV 10/100% NATL SV 15/100% NATL SV 10/100A NATL SV 10/250A NATL SV 15/250A NATL SV 15/100A NATL NATL POS $15/80%/60% COBRA NATL POS $15/80%/60% COBRA 24HR NURSLINE WL-SH/GR08 SV 20-40/250D NAT'L CB 24HOUR NURSE LINE SH07 NATL POS $15/$150/70% CBRA NATL POS $15/$150/70% CBRA SV 5/100% NATL CB SV 10/100% NATL CB SV 15/100% NATL CB SV 10/100A NATL CB SV 10/250A NATL CB SV 15/250A NATL CB SV 15/100A NATL CB SV 5/100% NATL SV 10/100% NATL SV 15/100% NATL SV 10/100A NATL SV 10/250A NATL SV 15/250A NATL SV 15/100A NATL NATL POS $10/100%/70% CBRA NATL POS $10/100%/70% CBRA 23TL POS $10/90%/70% COBRA NATL POS $10/90%/70% COBRA NATL POS $10/100%/70% NATL POS $10/90%/70% NATL POS $15/80%/60% NATL POS $15/$150/70% NATL POS $10/100%/70% NATL POS $10/90%/70% NATL POS $15/80%/60% NATL POS $15/$150/70% NATL POS $15/80%/60% COBRA NATL POS $15/80%/60% COBRA NAT'L $20/$40/$400 DAY CBR NAT'L $10/$20/$100 COBRA NAT'L $15/$30/$250 COBRA NAT'L $15/$30/$400 COBRA NAT'L $20/$40/$250 DAY CBR NAT'L $20/$40/$400 DAY CBR NAT'L $10/$20/$100 COBRA 517 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit NR7 NR8 NR9 NRA NRB NRC NRD NRE NRF NRG NRH NRI NRJ NRK NRL NRM NRN NRO NRP NRQ NRR NRS NRT NRX NRZ NS1 NSH NSI NSL NSX NSZ NTB NTC NTF NTL NTQ NTS NTU NUF NV1 NV2 NV3 NVA NVB NVC NVF NW1 NW2 NW3 NWA Plan / Benefit Description NAT'L $15/$30/$250 COBRA NAT'L $15/$30/$400 COBRA NAT'L $20/$40/$250 DAY CBR NAT'L $10/$20/$100 NAT'L $15/$30/$250 NAT'L $15/$30/$400 NAT'L $20/$40/$250 PER DAY NAT'L $20/$40/$400 PER DAY NAT'L $10/$20/$100 NAT'L $15/$30/$250 NAT'L $15/$30/$400 NAT'L $20/$40/$250 PER DAY NAT'L $20/$40/$400 PER DAY NAT'L $10/$20/$100 NAT'L $15/$30/$250 NAT'L $15/$30/$400 NAT'L $20/$40/$250 PER DAY NAT'L $20/$40/$400 PER DAY NAT'L $10/$20/$100 NAT'L $15/$30/$250 NAT'L $15/$30/$400 NAT'L $20/$40/$250 PER DAY NAT'L $20/$40/$400 PER DAY NATL POS $15/$150/70% CBRA NATL POS $15/$150/70% CBRA NORTHSIDE IND.HOSP.COBRA NORTHSIDE ISD HIGH OPTION NORTHSIDE HOSP.INDEMNITY NORTHSIDE ISD LOW OPTION NORTHSIDE ISD LOW OPT COBR NORTHSIDE ISD HIGH OPT CBR 0/24-1W NON-ER TRANS SH07 0/24-1W NON-ER TRANS SH07 0/12-1W NON-ER TRANS SH07 0/24-1W NON-ER TRANS SH08 0/24-1W NON-ER TRANS SH08 0/12-1W NON-ER TRANS SH08 0/20-1W NON-ER TRANS SH08 SV 15-30/400A NAT'L CB $10/$0 MERCER PLAN 1 COBRA $15/$0 MERCER PLAN 2 COBRA $15/$500 MERCER PLAN3 CBRA $10/$0 MERCER PLAN 1 $15/$0 MERCER PLAN 2 $15/$500 MERCER PLAN3 SV 20-40/250D NAT'L CB $10/$0 MERCER PLAN 1 COBRA $15/$0 MERCER PLAN 2 COBRA $15/$500 MERCER PLAN3 CBRA $10/$0 MERCER PLAN 1 518 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit NWB NWC NWF NX1 NX2 NX3 NX4 NX5 NX6 NX8 NXA NXB NXC NXD NXE NXF NXG NY1 NY2 NY3 NY4 NY5 NY6 NY8 NYA NYB NYC NYD NYE NYF NYG O11 O1A O1B O1D O1F O1G O1J O1L O1Q O1R O1U O1V O1W O1X O1Y O2J O2L O2Q O2R Plan / Benefit Description $15/$0 MERCER PLAN 2 $15/$500 MERCER PLAN3 SV 20-40/400D NAT'L CB PHS NATL $5/100% CBRA PHS NATL $10/100% CBRA PHS NATL $10/$100 COBRA PHS NATL $10/$250 COBRA PHS NATL $15/$250 COBRA PHS NATL $15/100% COBRA PHS NATL $15/$100 COBRA PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100 PHS NATL $10/$250 PHS NATL $15/$250 PHS NATL $15/100% PHS NATL $15/$100 PHS NATL $5/100% CBRA PHS NATL $10/100% CBRA PHS NATL $10/$100 COBRA PHS NATL $10/$250 COBRA PHS NATL $15/$250 COBRA PHS NATL $15/100% COBRA PHS NATL $15/$100 COBRA PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100 PHS NATL $10/$250 PHS NATL $15/$250 PHS NATL $15/100% PHS NTL $15/$100 NAT'L PLN 2 $10 GRP RET NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET 10-15/50A T1A CC GR07 10-20/750A T2A CC GR07 10-20/750A T2A GR07 15-25/200D T3A GR07 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 15-25/200D T3A CC GR07 10-15/50A T1A CC GR07 10-20/750A T2A CC GR07 10-20/750A T2A GR07 15-25/200D T3A GR07 519 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit O2U O2V O2W O2X O2Y O3J O3L O3Q O3R O3U O3V O3W O3X O3Y O44 O4A O4B O4D O4F O4G O4J O4L O4Q O4R O4U O4V O4W O4X O4Y O5J O5L O5Q O5R O5U O5V O5W O5X O5Y O6J O6L O6Q O6R O6U O6V O6W O6X O6Y O7J O7L O7Q Plan / Benefit Description 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 15-25/200D T3A CC GR07 10-15/50A T1A CC GR07 10-20/750A T2A CC GR07 10-20/750A T2A GR07 15-25/200D T3A GR07 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 15-25/200D T3A CC GR07 NAT'L PLN 2 $10 GRP RET NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLAN 3B $15 GRP RET 5-20/100A T1B CC GR07 15-25/130D T2B CC GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 15-30/220D T3B CC GR07 5-20/100A T1B CC GR07 15-25/130D T2B CC GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 15-30/220D T3B CC GR07 5-20/100A T1B CC GR07 15-25/130D T2B CC GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 15-30/220D T3B CC GR07 10-20/200A T1C CC GR07 10-25/150D T2C CC GR07 10-25/150D T2C GR07 520 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit O7R O7U O7V O7W O7X O7Y O8J O8L O8Q O8R O8U O8V O8W O8X O8Y O9J O9L O9Q O9R O9U O9V O9W O9X O9Y OA1 OA4 OAN OB1 OB2 OB4 OCM OD1 OD2 OD4 ODB ODG ODM ODS ODU OE1 OE2 OE4 OEM OES OF1 OF2 OF3 OF4 OF5 OF6 Plan / Benefit Description 20-35/250D T3C GR07 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 20-35/250D T3C CC GR07 10-20/200A T1C CC GR07 10-25/150D T2C CC GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 20-35/250D T3C CC GR07 10-20/200A T1C CC GR07 10-25/150D T2C CC GR07 10-25/150D T2C GR07 20-35/250D T3C GR07 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 20-35/250D T3C CC GR07 NAT'L PLN 1 $5 GRP RET NAT'L PLN 1 $5 GRP RET NAT'L ACCT EXTENDED OOA NAT'L PLN 2 $10 GRP RET NAT'L PLN 2 $10 GR 06 NAT'L PLN 2 $10 GRP RET 15-25/500A AARP GR08 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 5/100% AARP GR08 DO NOT USE 15-25/500A AARP GR08 10/100% NON-AARP GR08 5/100% AARP GR08 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 15-25/500A AARP GR08 10/100% NON-AARP GR08 RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO 521 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit OF7 OF8 OF9 OFA OFB OFC OFD OFE OFS OFV OG1 OG2 OG4 OGD OGP OGV OH2 OH4 OHB OHV OI2 OJ1 OJ2 OJ4 OJB OJJ OJX OK1 OK2 OK4 OKJ OL1 OL2 OL4 OLJ OLP OM1 OM2 OM4 ON1 ON2 ON4 ONP OOB OOK OON OOR OOS OOT OP1 Plan / Benefit Description RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO 10/100% NON-AARP GR08 5/100% NON-AARP GR08 NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 NAT'L PLN 2D $20 GRP RET 20-40/250A NON-AARP GR08 5/100% NON-AARP GR08 NAT'L PLN 1 $5 GR 06 NAT'L PLN 1 $5 GR 06 5/100% AARP GR08 5/100% NON-AARP GR08 NAT'L PLN 2 $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 5/100% AARP GR08 15/250A AARP GR08 5/100% AARP GR08 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 15/250A AARP GR08 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 15/250A AARP GR08 20-40/250A NON-AARP GR08 NAT'L PLAN 3B $15 GR 06 NAT'L PLAN 3B $15 GR 06 NAT'L PLAN 3B $15 GR 06 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 20-40/250A NON-AARP C GR08 5/100% AARP GR08 15/250A NON-AARP GR08 POS - OUT OF AREA POS OUT OF AREA (AUSTIN) POS OUT OF AREA (HOUSTON) POS OUT OF AREA (DALLAS) NAT'L PLN 2C $20 GR 06 522 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit OP2 OP4 OPK OPX OQ2 OQ4 OQK OR2 OR3 OR4 ORF ORX OS2 OS4 OT1 OT2 OT4 OTF OUX OVR OVT OWF OWR OWT OXK OXR OXT OYK OZK P00 P0Z P2P P3P P4P P4Z P5P P5Z P6H P6P P6Z P70 P7P P7Z P80 P8P P8Z P9P P9Z PA2 PA3 Plan / Benefit Description NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 15/250A NON-AARP GR08 5/100% AARP GR08 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 15/250A NON-AARP GR08 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 10-20/250A NON-AARP GR08 OTHR RX NOT THRU RX SOL NAT'L PLN 1 $5 GR 06 NAT'L PLN 1 $5 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 10-20/250A NON-AARP GR08 5/100% AARP GR08 10/100% AARP GR08 10-20/250A AARP GR08 10-20/250A NON-AARP GR08 10/100% AARP GR08 10-20/250A AARP GR08 20-40/250A AARP GR08 10/100% AARP GR08 10-20/250A AARP GR08 20-40/250A AARP GR08 20-40/250A AARP GR08 INPATIENT PSYCHIATRIC 100% POS FLEX 10/0/800 99 COBRA RESERVED PPO RESERVED PPO RESERVED PPO POS FLEX 20/200/1000 99 CB RESERVED PPO POS FLEX 20/300/1200 99 CB 15-25/100A GR06 RESERVED PPO POS FLEX 20/400/1500 99 CB INPATIENT MENTAL HEALTH RESERVED PPO POS FLEX 25/600/2000 99 CB INPATIENT PSYCHIATRIC 80% RESERVED PPO BELL AAA POS IN-NET COBRA RESERVED PPO BELL POS 123 IN NET COBRA RESERVED PPO RESERVED PPO 523 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit PA4 PA5 PA6 PA7 PA8 PA9 PAA PAB PAC PAD PAE PAF PAG PAH PAK PB1 PB2 PB3 PB4 PB5 PB6 PB7 PB8 PBA PBB PBF PBG PCE PCF PCG PCH PCI PCW PD2 PD3 PD4 PD5 PD6 PD7 PDH PDL PDN PDS PDW PEH PEK PEY PF0 PF2 PF3 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PPO - PFFS RESERVED PFFS PPO ADMINISTRATIVE CHARGE PPO - PFFS PPO - PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS PPO CUSTOM PPO CUSTOM COBRA PPO CUSTOM PPO CUSTOM COBRA PPO CUSTOM PPO CUSTOM COBRA PPO CUSTOM PPO CUSTOM COBRA PPO - PFFS RESERVED PFFS RESERVED PFFS RESERVED PFFS PPO - PFFS SV 15-30/100A PC SV 15-30/100A PC SV 15-30/100A PC SV 15-30/100A PC $45/Q PHB CREDIT SH08 PDV CUSTOM DENTAL ONLY PDV VISION ONLY PDV CUSTOM VISION ONLY PDV DENTAL & VISION PDV CUSTOM DENTAL & VISION PDV DENTAL ONLY O/4V 1YR POD SH07 O/4V 1YR+SHOE POD SH07 O/6V 1YR POD SH07 O/3V 1YR POD SH08 O/6V 1YR POD SH08 RESERVED PFFS RESERVED PFFS $20/Q PHB CREDIT SH08 I/P PSYCHIATRIC CARE(FEDS) RESERVED PPO RESERVED PPO 524 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit PF4 PF5 PF6 PF7 PF8 PF9 PFA PFB PFC PFD PFJ PFL PFM PFZ PG1 PG2 PG3 PG4 PG5 PG6 PG7 PG8 PGD PH0 PH1 PH2 PH3 PH4 PH5 PH6 PH7 PH8 PH9 PHA PHB PHC PHD PHE PHF PHG PHH PHV PHZ PIE PIF PIG PIH PII PIK PIL Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 20-40/200A PHS 06 SV 20-40/200A PHS 06 CB SV 20-40/200A PHS 06 SV 20-40/200A PHS 06 CB SV 20-40/200A PHS 06 SV 20-40/200A PHS 06 CB SV 20-40/200A PHS 06 SV 20-40/200A PHS 06 CB PBG $20/$200 PBG $20/$200 COBRA PBG $20/$200 PBG $20/$200 COBRA PBG $20/$200 PBG $20/$200 COBRA PGB $20/$200 PBG $20/$200 COBRA PPO - PFFS POS FLEX 10/0/800 99 POS FLEX 10/300/1200 99 POS FLEX 15/300/1200 99 POS FLEX 15/400/1500 99 POS FLEX 20/200/1000 99 POS FLEX 20/300/1200 99 POS FLEX 20/400/1500 99 POS FLEX 25/600/2000 99 BELL AAA POS IN-NET BARG BELL POS 123 IN-NET PPO CUSTOM - HIGH OPTION PPO CUSTOM - HI-OPT COBRA PPO CUSTOM - HIGH OPTION PPO CUSTOM - HI-OPT COBRA PPO CUSTOM - HIGH OPTION PPO CUSTOM - HI-OPT COBRA CUSTOM PPO - HIGH OPTION PPO CUSTOM - HI-OPT COBRA $45/Q PHB CREDIT SH07 POS FLEX 10/300/1200 99 CB RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS 525 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit PIN PIO PL2 PL3 PL4 PLA PLB PLC PLD PLE PLF PLG PLH PLP PMZ PPA PPB PPC PPD PPE PPF PPG PPH PPJ PPK PPL PPM PPN PPQ PPR PPS PPT PPU PPV PPW PPX PPY PPZ PR1 PR2 PR3 PT1 PT2 PT3 PT4 PT5 PTZ PYI PZ1 PZ2 Plan / Benefit Description RESERVED RX PFFS RESERVED RX PFFS RESERVED PPO RESERVED PPO RESERVED PPO PPO CUSTOM - LOW OPTION PPO CUSTOM - LOW-OPT COBRA PPO CUSTOM - LOW OPTION PPO CUSTOM - LOW-OPT COBRA PPO CUSTOM - LOW OPTION PPO CUSTOM - LOW-OPT COBRA PPO CUSTOM - LOW OPTION PPO CUSTOM - LOW-OPT COBRA PAYMENT LAG PREMIUM ALLOC POS FLEX 15/400/1500 99 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PREFERRED PLAN PREFERRED PLAN (2) PREFERRED PLAN $5G/$15BR $1500 BRND MAX $5G/$25BR $1000 CMBND MAX $5G/$20BR $1200 CMBND MAX UFCW $3G/$6BR UNLIMITED $5G/$15BR $1200 BRND MAX POS FLEX 15/300/1200 99 CB RESERVED PFFS PREFERRED PLAN (COBRA) PREFERRED PLAN (COBRA) (2) 526 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit PZ3 PZF PZG PZH PZI QAC QAZ QBC QBI QBZ QCC QCZ QDC QDG QDZ QIK R01 R02 R03 R04 R05 R06 R07 R08 R10 R12 R2B R34 R3B R4B R4C R4Z R5B R5C R5Z R6B R6C R6Z R7C R7Z R8C R8Z R9C R9Z RA3 RA4 RA5 RA6 RA8 RAC Plan / Benefit Description PREFERRED PLAN (COBRA) (3) SV 15-30/100A PC CB SV 15-30/100A PC CB SV 15-30/100A PC CB SV 15-30/100A PC CB $20 PLAN $20 PLAN COBRA $20 PLAN QUALITY BUSINESS INCENTIVE $20 PLAN COBRA $20 PLAN $20 PLAN COBRA $20 PLAN *OK TO USE*LOADED IN ERROR $20 PLAN COBRA INDEPENDENT $20 PLAN REGION LG $20-$40/$250 DAY REGION $20-$40/$250 DAY CB REGION LG $20-$40/$250 DAY REGION $20-$40/$250 DAY CB REGION LG $20-$40/$250 DAY REGION $20-$40/$250 DAY CB REGION LG $20-$40/$250 DAY REGION $20-$40/$250 DAY CB $10 $12G/$25B $7G/$14B $5 $10G/$20B $10G/$25B $10/$250 NAT'L ACCT PLAN $10/$250 NAT'L ACCT COBRA $10G/$20B/$40NF $10/$250 NAT'L ACCT PLAN $10/$250 NAT'L ACCT COBRA $15G/$25B/$40NF $10/$250 NAT'L ACCT PLAN $10/$250 NAT'L ACCT COBRA $10/$250 NATIONAL FOLEYS $10/$250 NATL FOLEYS COBRA $10/$250 NATIONAL FOLEYS $10/$250 NATL FOLEYS COBRA $10/$250 NATIONAL FOLEYS $10/$250 NATL FOLEYS COBRA $7G/$14B $10G/$20B $10G/$25B $10G/$20B/$40NF $15G/$25B/$40NF $10/$250 NATIONAL FOLEYS 527 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit RAZ RB4 RB6 RB7 RB8 RB9 RD5 RE1 RE2 RE3 RE4 RE5 RE6 RE7 RE8 REA REB REC RED REE REF REG REH RF5 RGM RH1 RH2 RH3 RH4 RH5 RJD RJW RP5 RPE RPX RS0 RS1 RS2 RS4 RS5 RS6 RS7 RS8 RSA RSB RSI RST RT5 RX0 RX1 Plan / Benefit Description $10/$250 NAT'L FOLEYS COB $7G/$14B $10G/$20B $10G/$25B $10G/$20B/$40NF $15G/$25B/$40NF $5G/$15B 1800 ANN MAX RX REED ELSE $10-$20/$250 REED ELSE $10-$20/$250 CBR REED ELSE $10-$20/$250 REED ELSE $10-$20/$250 CBR REED ELSE $10-$20/$250 REED ELSE $10-$20/$250 CBR REED ELSE $10-$20/$250 REED ELSE $10-$20/$250 CBR SWR 10-40/100D 5M SWR 10-40/100D 5M COBRA SWR 10-40/100D 5M SWR 10-40/100D 5M COBRA SWR 10-40/100D 5M SWR 10-40/100D 5M COBRA SWR 10-40/100D 5M SWR 10-40/100D 5M COBRA $5 $7G/$15B/$15NF FMR HRRS RT$5OV/$25ER/$5UR FMR HRRS RT $0 OV/$0 ER&UR FMR HRRS RT $7OV/50ER/25UR FMR HRRS RT $5OV/25ER/5UR FMR HRRS RT $5OV/50ER/25UR J.C. PENNY 10/200 J.C. PENNEY 10/200 COBRA $5 RESPITE/PERS CARE SH07 RESPITE/PERS CARE WL-SH08 $15G $10 $10G/$30B $10G $5G/$25B 1200 ANN.MAX. $6G/$20B $10G/$30B/100%NF $10G/$30B $6G/$20B $6G/$20B INDEMNITY PHARMACY BENEFIT $5G/$25B 1800 ANN.MAX. $5G/10B $0 $1 528 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit RX2 RX3 RX4 RX5 RX6 RX7 RX8 RX9 RXA RXB RXC RXD S00 S10 S12 S13 S1C S1Z S70 S80 SA1 SA2 SER SF9 SFC SFD SH0 SH1 SH2 SH4 SH5 SH6 SH7 SH8 SH9 SHB SHC SHD SHE SHF SHG SHH SHJ SHK SHL SHM SHN SHO SHP SHR Plan / Benefit Description X2 $3 $4 $5 $6 $7 $8 $9 $5G/$10B $5G/$10B $5G/$10B PHARMACY DISCOUNT SERIOUS MENTAL ILL. (100%) STANDARD 10 PLAN STANDARD 10 PLAN (2) STANDARD 10 PLAN (3) DUMMY CODE DUMMY CODE SERIOUS MENTAL ILL. (70%) SERIOUS MENTAL ILL. (80%) SAN ANTONIO AREA-SH INDIV. SA AREA-SH INDV.PRT B ONLY SUPP ELIGIBILITY RIDER SECURE HORIZ. B ONLY PLAN SPLIT FAMILY COVERAGE $10/$30/$60 SF SPEECH & HEARING SECURE HORIZONS STANDARD SECURE HORIZONS B-ONLY SA SH STANDARD PLAN SECURE HORIZON GP RETIREE SH RETIREE $6 OV SA SH STANDARD PLAN PRT B HOUSTON SH STANDARD PLAN HOUSTON SH STANDARD PRT B DALLAS SH STANDARD PRT B SA SH STANDARD PLAN $10 FHP SENIOR PLAN/SILVER DNT TX SH STANDARD PLAN SECURE HORIZ. B ONLY PLAN FHP SENIOR PLAN FHP SENIOR PLAN PART B TX SH STANDARD PLAN TX SH STANDARD PLAN PART B TX SH STANDARD PLAN PART B TX SH STANDARD PLAN TX SH PART B DALLAS SH STANDARD PLAN FHP SENIOR PLAN PLUS RETIREE GOLD SENIOR FHPS 529 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit SHS SHT SHU SM1 SM7 SM8 SMA SMB SMC SMD SME SMF SMG SMH SMJ SMK SML SMM SMN SMO SMP SMQ SMR SMS SMT SMU SMV SMW SMY SMZ SP1 SR5 SR6 SS2 SS4 SS6 SS7 SS9 SSB SSE SSG SSH SSI SSJ SSK SSM SSP SSR SST ST1 Plan / Benefit Description SECURE HORIZONS PLAN TX SH STANDARD PLAN TX SH PART B SERIOUS MENTAL ILL. 100% SERIOUS MENTAL ILL. 70% SERIOUS MENTAL ILL. 80% SERIOUS MENTAL ILL. (70%) SERIOUS MENTAL ILL (80%) SERIOUS MENTAL ILL. (100%) SERIOUS MENTAL ILL. (90%) SERIOUS MENTAL ILL $0 I/P SERIOUS MENTAL ILL $100 IP SERIOUS MENTAL ILL $250 IP SMI IP&OP OP$15/60V MERCER SMI $10OV/0IP FLEX 193-4 SMI $10OV/300IP FLEX 189-3 SMI $15OV/300IP FLEX 108-3 SERIOUS MENTAL ILL. $400 SMI $15OV/400IP FLEX 109-3 SERIOUS MENTAL ILL. $600 SMI $20OV/200IP FLEX 219-3 SMI $20OV/300IP FLEX 106-4 SMI $20OV/400IP FLEX 100-3 SERIOUS MENTAL ILL. $150 SMI $25OV/600IP FLEX 123-3 SERIOUS MENTAL ILL (100%) SMI - CUSTOM GENERAL MOTOR SERIOUS MENTAL ILL $250 IP SERIOUS MNTL ILL 100% FEDS SERIOUS MENTAL ILL - SG SUPPLEMENTAL LIFE BENE SH GRP RET $5/100% 2001 SH GRP RET $6/100% 2001 SMI $15OV/200IP SFLEX 99-3 SMI $15OV/100IP SFLX 103-4 SMI $10OV/200IP SFLX 110-3 SMI $15OV/20%IP SFLEX 92-3 SECURE HORIZONS STANDARD SECURE HORIZONS B-ONLY SMI $15OV/300IP SFLX 107-4 SMI $20OV/400IP SFLX 101-4 SMI $15OV/400IP SFLEX 98-3 SMI $25OV/600IP SFLX 114-2 SMI $20OV/300IP SFLX 102-4 SMI $10OV/300IP SFLX 119-3 SMI $25OV/600IP SFLX 114-3 SH SILVER SNEAKERS SLV SNEAK/FITNESS BEN GR06 SECURE HORIZONS STANDARD STANDARD PLAN 530 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit ST2 ST3 ST5 STD SWK SWV SZ0 SZ1 SZ2 SZ3 SZ5 SZE T0Z T1S T1X T2A T2S T2Z T3A T3P T3Z T4A T4P T4Z T5A T5Z T6A T6Z T7Z T8Z T9Z TA1 TA6 TAK TAW TAX TBZ TC1 TC2 TC3 TC4 TCA TCB TCC TCD TCZ TDA TDB TDC TDD Plan / Benefit Description STANDARD PLAN STANDARD PLAN STANDARD 5 PLAN RESERVED FOR PPO LIFE WALLA WALLA POS PLAN WALLA WALLA POS PLAN-COBRA STANDARD 10 PLAN (COBRA) STANDARD PLAN (COBRA) STANDARD PLAN (COBRA) (2) STANDARD PLAN (COBRA) (3) STANDARD 5 PLAN EMP. RET. SYS. STATE COBRA PPO 0/10/200 98 IN NET CBR TX SG HMO $20/$40/$250D CB PPO 0/10/300 98 IN NET CBR TX SH STANDARD PLAN TX SG HMO $20/$40/$250D CB PPO 0/15/200 98 IN-NET CBR TX SH STANDARD PLAN PART B 15-20/100A GR06 PPO 0/15/300 IN-NET CBR TX SH STANDARD PLAN 05 5-10/100% GR06 PPO O/14/400 98 IN-NET CBR TX SH STD PLAN PART B 05 PPO 0/20/300 98 IN-NET CBR TX SH STANDARD PLAN W/D PPO 0/20/300A 98 IN-NETCBR PPO 0/20/400 98 IN-NET CBR PPO 0/25/600 98 IN-NET CBR PPO 100/15/90% 98 IN-NETCB TEXAS A&M PLAN 0/24T NON-ER TRANS SH-06 5-15/75D ATAS/KEN SH05 TEXAS A&M PLAN - COBRA TAX PCTX PREMIUM TAX PPO 250/10/90% 98 IN-NETCB LOCKHEED $0/100% COBRA LOCKHEED $0/100% COBRA LOCKHEED $0/100% COBRA LOCKHEED $0/100% COBRA LOCKHEED $0/100% LOCKHEED $0/100% LOCKHEED $0/100% LOCKHEED $0/100% PPO 250/20/80% 98 IN-NETCB TX SH STANDARD PLAN TX SH STANDARD PLAN PART B TX SH STANDARD-D/C TX SH STANDARD PLAN 05 531 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit TDE TDF TDZ TEZ TF1 TF2 TF3 TF4 TF5 TFZ TGA TGZ TH0 TH1 TH2 TH3 TH4 TH5 TH6 TH7 TH8 TH9 THA THB THC THD THE THF THG THH THJ THZ TI1 TI2 TI3 TI4 TI5 TI6 TI7 TI8 TIA TIB TIC TID TIT TJZ TKA TKZ TL1 TL2 Plan / Benefit Description TX SH STD PLAN PART B 05 TX SH STANDARD PLAN W/D PPO 250/20/90% 98 IN-NETCB PPO 300/20/80% 98 IN-NETCB TEXAS PLAN I LIMITED FEE TEXAS PLAN II LIMITE FEE TEXAS PLAN III LIMITED FEE TEXAS PLAN IV LIMITED FEE TEXAS PLAN V LIMITED FEE PPO 500/15/80% 98 IN-NETCB 0/50A SECURE GOLD SH05 PPO 500/25/80% 98 IN-NETCB PPO 0/10/200 98 IN NET PPO 0/10/300 98 IN NET PPO 0/15/200 98 IN-NET PPO 0/15/300 IN-NET PPO O/15/400 98 IN-NET PPO 0/20/300 98 IN-NET PPO 0/20/300A 98 IN-NET PPO 0/20/400 98 IN-NET PPO 0/25/600 98 IN-NET PPO 100/15/90% 98 IN-NET PPO 250/15/80%C 98 IN-NET PPO 250/10/90% 98 IN-NET PPO 250/20/80% 98 IN-NET PPO 250/20/90% 98 IN-NET PPO 300/20/80% 98 IN-NET PPO 500/15/80% 98 IN-NET PPO 500/25/80% 98 IN-NET CFW PPO 200/15/80% 98 IN PPO JCPENNY IN-NET CFW PPO 200/15/80% 98 INCB REGIONAL LG $20/80% REGIONAL LG $20/80% COBRA REGIONAL LG $20/80% REGIONAL LG $20/80% COBRA REGIONAL LG $20/80% REGIONAL LG $20/80% COBRA REGIONAL LG $20/80% REGIONAL LG $20/80% COBRA TX-SA SECURE GOLD TX-D SECURE GOLD TX-SA SECURE GOLD 05 TX-D SECURE GOLD 05 TRANSPORTATION S GOLD PPO JC PENNY IN NET COBRA 5-15/75D ATAS/KEN W/D SH05 PPO 250/15/80%C 98 IN CBRA TX LG HMO $20/100% COBRA TX LG HMO $20/100% COBRA 532 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit TL3 TL4 TL5 TL6 TL7 TL8 TLA TLB TLC TLD TLE TLF TLG TLH TLI TLJ TLK TLL TLW TLX TLY TLZ TN1 TN2 TN3 TN4 TN5 TN6 TN7 TNS TP3 TP4 TPH TPL TS0 TS1 TS2 TS3 TS4 TS5 TS6 TS7 TS8 TS9 TSA TSB TSC TSD TSE TSF Plan / Benefit Description TX LG HMO $20/100% COBRA TX LG HMO $20/100% COBRA TX LG HMO $20/$400 COBRA TX LG HMO $20/$400 COBRA TX LG HMO $20/$400 COBRA TX LG HMO $20/$400 COBRA TX LG HMO $20/100% TX LG HMO $20/100% TX LG HMO $20/100% TX LG HMO $20/100% TX LG HMO $20/$400 TX LG HMO $20/$400 TX LG HMO $20/$400 TX LG HMO $20/$400 TX LG HMO $20/80% TX LG HMO $20/80% TX LG HMO $20/80% TX LG HMO $20/80% TX LG HMO $20/80% COBRA TX LG HMO $20/80% COBRA TX LG HMO $20/80% COBRA TX LG HMO $20/80% COBRA $15G/$25B $15G/$35B $10G/$35B $10G/$20B/$30NF $10G/$25B/$50NF $10G/$25B/$40NF $15G/$25B/$40NF 5-15/75D N-SP W/D SH05 TOWERS PERRIN $15 PLAN TOWERS PERRIN $15 PLAN 5-10/100% GR06 15-20/100A GR06 TX SG HMO $20/$40/$250D CB TX SG HMO $10/$200 COBRA TX SG HMO $10/$200 COBRA TX SG HMO $10/$200 COBRA TX SG HMO $10/$200 COBRA TX SG HMO $20/$400 COBRA TX SG HMO $20/$400 COBRA TX SG HMO $20/$400 COBRA TX SG HMO $20/$400 COBRA TX SG HMO $20/$40/$250D CB TX SG HMO $10/$200 TX SG HMO $10/$200 TX SG HMO $10/$200 TX SG HMO $10/$200 TX SG HMO $20/$400 TX SG HMO $20/$400 533 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit TSG TSH TSI TSJ TSK TSL TSN TU1 TU2 TU3 TU4 TU5 TU6 TZ2 TZ3 U01 U02 U03 U04 U05 U06 U07 U08 U09 U10 U11 U12 U13 U14 U15 U16 U17 U18 U19 U20 U21 U22 U23 U24 U25 U26 U27 U28 U29 U30 U31 U32 U33 U34 U35 Plan / Benefit Description TX SG HMO $20/$400 TX SG HMO $20/$400 TX SG HMO $20/$40/$250D TX SG HMO $20/$40/$250D TX SG HMO $20/$40/$250D TX SG HMO $20/$40/$250D 5-15/75D N-SP SH05 TEXAS SM GRP PLAN I UC TEXAS SM GRP PLAN II UC TEXAS SM GRP PLAN III UC TEXAS SM GRP PLAN IV UC TEXAS SM GRP PLAN V UC TEXAS SM GRP INDEMNITY UC STANDARD 10 PLAN (COBRA 2) STANDARD 10 PLAN (COBRA 3) USUSAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUSAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUSAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PP9O USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO 534 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit U36 U37 U38 U39 U40 U41 U42 U43 U44 U45 U46 U47 U48 U49 U50 U51 U52 U53 U54 U55 U56 U57 U58 U59 U60 UHC UTC UTS UZS V07 V12 V15 V17 V1A V1B V1C V1D V20 V22 V23 V25 V27 V28 V2C V2D V2F V30 V32 V3A V3B Plan / Benefit Description USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO DUAL-OPTION - UHC 06 TAKING CHARGE OF YOU UNIVERSITY OF TEXAS UNIVERS. OF TEXAS (COBRA) VISION CARE $7 (VSP) VISION CARE $12 (VSP) VISION CARE $15 (VSP) FISION CARE $5REF/$12MAT STANDARD $15 POS PLAN STANDARD $15 POS PLAN CBRA POS 15/90/70 POS 15/90/70 COBRA VISION CARE $8REF/$12MAT VISION CARE $10REF/$12MAT VISION CARE $23 (VSP) VISION CARE $5REF/$20MAT SC 20 ELIGIBILITY ONLY VISION CARE $8REF/$20MAT POS 15/90/70 POS 15/90/70 COBRA 25/70A TOWERS GR-VN06 VSP VISION CARE $10REF/$20MAT VISION CARE $20REF/$12MAT STANDARD $15 POS SMALL GRP STANDARD 15 POS SMALL CBRA 535 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit V3C V3D V3S V40 V4A V4B V4C V4D V4S V5A V5B V5C V5D V5S V6A V6B V6C V6D V6S V7A V7B V7C V7D V8A V8B V8C V8D V8P V8Q V8R V8S V8T V8U V8V V8W V8X V9A V9B VA6 VAA VAB VAC VAD VAE VAF VAG VAH VAI VAJ VAK Plan / Benefit Description POS 15/90/70 POS 15/90/70 COBRA SH $15/$150 ALLOWANCE VISION CARE $20REF/$20MAT STANDARD $15 POS SMALL GRP STANDARD $15 POS SMALL CBR POS 15/90/70 POS 15/90/70 COBRA SH $20/$150 ALLOWANCE $15 POS $15 POS COBRA POS 15/80/60 POS 15/80/60 COBRA $5/$100 ALLOW S GOLD $15 POS $15 POS COBRA POS 15/80/60 POS 15/80/60 COBRA SH 25/150 ALLOWANCE (COLE) $15 POS $15 POS COBRA POS 15/80/60 POS 15/80/60 COBRA $15 POS $15 POS COBRA POS 15/80/60 POS 15/80/60 COBRA 0 REFRAC 1/V YR VN-GR08 5 REFRAC 1/V YR VN-GR08 10 REFRAC 1/V YR VN-GR08 15 REFRAC 1/V YR VN-GR08 20 REFRAC 1/V YR VN-GR08 25 REFRAC 1/V YR VN-GR08 30 REFRAC 1/V YR VN-GR08 35 REFRAC 1/V YR VN-GR08 40 REFRAC 1/V YR VN-GR08 STANDARD $15 POS PLAN STANDARD $15 POS PLAN COB 5/100A 2 YRS SH-VN06 VISION $3 REF/$65 ALLOW. VISION $5 REF/$65 ALLOW. VISION $8 REF/$65 ALLOW. VISION $10 REF/$65 ALLOW. VISION $20 REF/$65 ALLOW VISION $3 REF/$100 ALLOW. VISION $5 REF/$100 ALLOW. VISION $8 REF/$100 ALLOW. VISION $10 REF/$100 ALLOW. VISION $20 REF/$100 ALLOW VISION $3 REF/$125 ALLOW. 536 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit VAL VAM VAN VAO VAP VAQ VAR VAS VAT VB6 VDA VFP VFQ VG6 VGP VGQ VH1 VH2 VH4 VH5 VH6 VJQ VKP VMQ VN1 VN2 VN5 VNQ VP6 VPE VPP VQC VQD VQF VQG VQJ VQK VQL VQP VQR VQT VQX VRR VS1 VS2 VS3 VSE VSF VSG VSK Plan / Benefit Description VISION $5 REF/$125 ALLOW. VISION $8 REF/$125 ALLOW. VISION $10 REF/$125 ALLOW. VISION $20 REF/$125 ALLOW. VISION $5 REF/$100 ALLOW. VISION $10 REF/$100 ALLOW. VISION $15 REF/$100 ALLOW. VISION $20 REF/$100 ALLOW. VISION $25 REF/$100 ALLOW. 25/150A 2 YRS SH-VN06 15/70A GR-VN07 0/75A 2YRS VN-GR08 0/125A 2YRS VN-GR08 25/75A VN-GR06 5/75A 2YRS VN-GR08 5/125A 2YRS VN-GR08 SENIOR VISION 7 OV/100 ALW VISION SUPP $10 COPAY VISION SUPP $5 COPAY VISION SUPP $15 COPAY VISION PPO SUPPLEMENT 10/75 2YRS VN-GR08 10/125A 2YRS VN-GR08 15/125A 2YRS VN-GR08 GRP RET $5OV/$125 ALLOWNCE GRP RET $10OV/$75 ALLOWNCE GRP RET $20V/$75 ALLOWANCE 20/75A 2YRS VN-GR08 ADVANCE WELLNESS SH-WL06 RESERVED PFFS 20/125A 2YRS VN-GR08 15/130A 1YR DLX VN-SH08 30/70A 2YRS VN-SH08 0/130A 2YRS VN-SH08 25/150A 2YRS VN-SH08 5/100A 2YRS VN-SH08 0/75A 2YRS VN-SH08 0/300A 2 YRS+GLS VN-SH08 25/70A 2YRS VN-GR08 0/70A 2YRS VN-SH08 0/100A 2YRS VN-SH08 0 1YR/100A 2YRS VN-SH08 10/75A GR-VN07 SENIOR VISION 7 OV/100 ALW SENIOR VISION 5 OV/100 ALW SENIOR VISION 0 OV/100 ALW 0/75A 2YRS SH-VN07 0/130A 2YRS SH-VN07 0/300A 2 YRS+GLS SH-VN07 5/100A 2YRS SH-VN07 537 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit VSM VSQ VSX VV1 VV2 VV3 VV4 VV5 VV6 VV7 VVP VVQ VWP VWQ WAP WB6 WEL WIK WJR WJS WJT WLQ WLR WLT WPR WPS WPT WQR WQS WQT WRR WRS WRT WUR WUS WUT WVR WVS WVT WXR WXS WXT WYR WYS WYT X10 X5M XA5 XAA XAB Plan / Benefit Description 25/150A 2YRS SH-VN07 30/70A 2YRS SH-VN07 15/130A 1YR DLX SH-VN07 VISION STANDARD $0 COPAY VISION STANDARD $5 COPAY VISION STANDARD $10 COPAY VISION STANDARD $15 COPAY VISION STANDARD $20 COPAY VISION STANDARD $25 COPAY VISION STANDARD $30 CO-PAY 15/75A 2YRS VN-GR08 25/75A 2YRS VN-GR08 25/125A 2YRS VN-GR08 0/70A 2YRS VN-GR08 RESERVED WT ALT PROGRAM HLTH EDUC SH-WL06 SUPPLEMENTAL WELLNESS INDEPENDENT $15 PLAN 10-15/50A T1A CC GR07 5-20/100A T1B CC GR07 10-20/200A T1C CC GR07 10-20/750A T2A CC GR07 15-25/130D T2B CC GR07 10-25/150D T2C CC GR07 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 15-25/200D T3A CC GR07 15-30/220D T3B CC GR07 20-35/250D T3C CC GR07 $10G/$15B $5G/ $5B $5 $5G/$15B $5G/$20B 538 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit XAC XAD XAE XAF XAG XAH XAT XGM XGS XM0 XM1 XM2 XM3 XM4 XM5 XM6 XM7 XM8 XM9 XMA XMB XMC XMD XME XMF XMG XMH XMI XMJ XMK XML XMM XMN XMO XMP XMQ XMR XMT XMU XMW XNN XP5 XPA XPB XPC XPD XTU XXX YXA YXJ Plan / Benefit Description $5G/$25B $10G/$20B $10G/25B $10 $10G/$30B $5G/$10B $10G/$30B $2G/$2B OPEN FORMULARY $5G/$5B OPEN FORMULARY $0 $1 $2 $3 $4 $5 $6 $7 $8 $9 $10 $5G/$10B $5G/$15B $5G/$20B $5G/$25B $10G/$20B $10G/$25B $10G/$30B $8G/$12B $10G/$15B $10 $5GF/$10BF $5GF/$15BF $10GF/$15BF $10GF/$25BF $5/$10/$25 $5GF/$10BF $5/$10/$25 $5GF/$10BF $5G/$10BR CUSTOM $5G/$5B OPEN FORMULARY DO NOT USE $5 $10 $5/$15/70% $10/$25/60% $10/$25/70% $5G/$5B OPEN FORMULARY PREMIUM ALLOCATION SV 35/240A W/BH9 06 SV 35/240A W/BH9 06 CB 539 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit YYA YYB YYJ YYX YZC YZZ Z2J Z2M Z2P Z2R Z2T Z2U Z2V Z2X Z2Y Z5M Z5R Z5V Z8J Z8P Z8X ZA2 ZA3 ZA4 ZA5 ZA6 ZA7 ZA8 ZA9 ZB2 ZB3 ZB4 ZB5 ZB6 ZB7 ZB8 ZB9 ZC2 ZC3 ZC4 ZC5 ZC6 ZC7 ZC8 ZC9 ZD2 ZD3 ZD4 ZD5 ZD6 Plan / Benefit Description SV 35/240A W/BH9 06 SV 35/240A W/BH9 06 CB SV 35/240A W/BH9 06 SV 35/240A W/BH9 06 CB SV 35/240A W/BH9 06 SV 35/240A W/BH9 06 CB 10-15/50A T1A NON-AARP GR8 10-20/750A T2A NO-AARP GR8 10-15/50A T1A NON-AARP GR8 10-20/750A T2A NO-AARP GR8 15-25/200D T3A NO-AARP GR8 15-25/200D T3A NO-AARP GR8 10-20/750A T2A NO-AARP GR8 10-15/50A T1A NON-AARP GR8 15-25/200D T3A NO-AARP GR8 15-25/130D T2B NO-AARP GR8 15-25/130D T2B NO-AARP GR8 15-25/130D T2B NO-AARP GR8 10-20/200A T1C NO-AARP GR8 10-20/200A T1C NO-AARP GR8 10-20/200A T1C NO-AARP GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 540 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit ZD7 ZD8 ZD9 ZE2 ZE3 ZE4 ZE5 ZE6 ZE7 ZE8 ZE9 ZF2 ZF3 ZF4 ZF5 ZF6 ZF7 ZF8 ZF9 ZG2 ZG3 ZG4 ZG5 ZG6 ZG7 ZG8 ZG9 ZH2 ZH3 ZH4 ZH5 ZH6 ZH7 ZH8 ZH9 ZJ2 ZJ3 ZJ4 ZJ5 ZJ6 ZJ7 ZJ8 ZJ9 ZK2 ZK3 ZK4 ZK5 ZK6 ZK7 ZK8 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 541 of 640 Plan Benefit - TX State TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX TX Plan / Benefit ZK9 ZM2 ZM3 ZM4 ZM5 ZM6 ZM7 ZM8 ZM9 ZN2 ZN3 ZN4 ZN5 ZN6 ZN7 ZN8 ZN9 ZP2 ZP3 ZP4 ZP5 ZP6 ZP7 ZP8 ZP9 ZR2 ZR3 ZR4 ZR5 ZR6 ZR7 ZR8 ZR9 ZZZ Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO HISTORICAL PLAN 542 of 640 Plan Benefit - WA Cap/Eligibility CP7810 Assigned Plan Benefit Codes & Descriptions State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 11C 1C1 1LL 1MS 1U7 1WS 1ZL 213 21C 21U 22U 23C 23U 24C 24U 25U 26U 27U 28U 29U 2AL 2AN 2AT 2AY 2BL 2BU 2C4 2CA 2CJ 2CK 2EU 2FH 2FL 2GH 2HH 2JH 2KH 2KU 2LU 2MH 2MU 2NH Plan / Benefit Description $0 $7/$7 INDIVIDUAL CONV-COMPREHNSV 15 SH-RX05 UNAVIAL DO NOT USE IN WA $9G SH INDIVIDUAL CONV-MAJOR RESERVED FOR PREMIER PASS $5G/$10B $5G/$10B $5G/$15B $9G/$15B $5G/$20B $7.50G/$15B $5G/$25B $10G/$20B $10G/$25B $10G/$35B $15G/$25B $15G/$35B INDIVIDUAL CONV-BASIC 4/20/40 LO GR-RX07 5/15 RX 06 4/25/50 HI GR-RX07 10/25/50 RX-GR08 $5G/$15B $5G/$15B AT&T $5G/$15B $5G/$15B $10G/$20B $10G/$20B 4/15/30 RX-GR08 5/20/45 RX-GR08 4/20/40 RX-GR08 4/15/30 RX-GR08 4/20/40 RX-GR08 4/25/50 RX-GR08 $5/10 W/INF $5/15 W/INF 4/25/45 RX-GR08 $10/20 W/INF 4/28/55 RX-GR08 543 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 2NU 2ON 2OU 2P2 2PH 2PU 2QH 2QU 2S1 2S2 2S3 2S4 2S5 2S6 2S7 2SA 2SB 2SC 2SD 2SE 2SF 2SH 2U1 2U2 2U3 2U4 2U5 2U6 2U7 2UA 2UB 2UC 2UD 2UE 2UF 2UH 2VH 2WH 2XH 2YH 2ZA 2ZB 2ZC 2ZD 2ZE 2ZF 3 31C 31S 32C Plan / Benefit Description $10/25 W/INF POS-OUT OF NETWORK $10/35 W/INF RESERVED 2003 SH CODE 4/28/58 RX-GR08 $15/25 W/INF 4/25/50 RX-GR08 $15/35 W/INF $5G/$10B $5G/$15B $5G/$20B $5G/$25B $10G/$20B $10G/$25B $10G/$35B $15G/$40B $5G/$15B $10/20 $10/25 $10G/$20B $10/35 $15/40 $5G/$10B $5G/$15B $5G/$20B $5G/$25B $10G/$20B $10G/$25B $10G/$35B DO NOT USE IN WA OR RX CODE DONT USE IN WA DO NOT USE IN WA RX CODE DO NOT USE IN WA OR RX CODE DONT USE IN WA OR RX CODE DONT USE IN WA 10/25/50 RX-GR08 10/25/50 RX-GR08 5/20/45 RX-GR08 5/20/45 RX-GR08 4/10/20 RX-GR08 0/0 GR-RX07 2/40 GR-RX07 5/25 GR-RX07 5/65 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 CODE INCOMPLETE $5/$10/$15 $10/$20/50% $10/$20/$30 544 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 32S 33C 33S 33U 34C 35C 35U 36C 36U 37C 37U 38C 38U 39C 39U 3AC 3AL 3AU 3B6 3BC 3BD 3BE 3BU 3C1 3C2 3C4 3C5 3C6 3C7 3C8 3C9 3CA 3CU 3CW 3CY 3D1 3D2 3D3 3D4 3D5 3D6 3D7 3D8 3DE 3EA 3FC 3FD 3GA 3GB 3GF Plan / Benefit Description $10/15/30 $10/$20/$30 $15/25/40 $10/$15/$30 $0/$0/$0 $5/$10/$25 $5/$10/$25 $8G/$13B/$28NF $10G/$20B/$30NF $5G/$10B/$10NF $10G/$25B/$40NF $10G/$25B/$40NF $10G/$25B/$50NF $10G/$20B/$40NF $15G/$25B/$40NF $10G/$20B/$30NF 5/10/25 WSD RX05 $10/20/45 W/INF E 15/30/50/100D RX06 $10/20/35 W/O INF 10/20/35 UNDER LAB 5/10/25 RX 06 $10/30/50 W/INF E $10/$15/$30 $10/$20/$30 $0/$0/$0 $10G/$15B/$25NF $10G/$25B/$50NF $10G/$20B/$35NF $10G/$25B/$40NF $10G/$20B/$40NF 5/10/25 RX 06 $15/25/50 W/INF E $10G/$25B/$50NF WF 10G/20B/35NF I VBA $15G/$25B/$40NF $100 DED $15G/$25B/$40NF $200 DED $15/30/50/100D E $15/35/60/200D E $15/25/40/$100D $15/25/40/$200D $15/30/50/$100D E $15/35/60/$200D E 15/30/50 RX 08 RESERVED FIDELITY RX 06 10/30/50 RX05 15/30/60 RX06 SF $15G/$25B/$40NF 15G/25B/40NF W/INJ 20/30/45 RX 07 545 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 3HA 3HC 3HP 3JC 3JU 3KU 3LU 3MU 3NU 3OU 3PC 3PD 3PH 3PU 3QU 3S1 3S2 3S3 3S4 3S5 3S6 3SC 3SD 3SE 3SH 3SJ 3SK 3TU 3U1 3U2 3U3 3U4 3U5 3U6 3U7 3U8 3U9 3UA 3UB 3UC 3UD 3UE 3UF 3UG 3UH 3UI 3UJ 3UK 3UN 3W3 Plan / Benefit Description 10/30/45 RX 06 10G/25B/40NF I HP 5/30/45 GR-RX07 0/0/0 RX 07 $5/10/25 W/INF $10/15/30 W/INF $10/20/30 W/INF $10/25/40 W/INF $10/25/50 W/INF $15/25/40 W/INF 10G/30B/40NF E W/I 10/20/40 RX06 10/30/50 RX06 $10/20/45 W/INF E $10/30/50 W/INF E $3/$8/$23 $8/$13/$28 $15/$25/$40 $7/$12/$27 $5G/$10B/$25NF $10G/$15B/$30NF $10G/$20B/$45NF E $10G/$30B/$50NF E $15G/$25B/$50NF E $10/20/45 E $10/30/50 E $15/25/50 E $15/25/50 W/INF E DO NOT USE IN WA DO NOT USE IN WA $10/$15/$30 DO NOT USE IN WA $5/$10/$25 DO NOT USE IN WA DO NOT USE IN WA DO NOT USE IN WA DO NOT USE IN WA OR RX CODE DONT USE IN WA OR RX COD DONT USE IN WA OR RX CODE DONT USE IN WA OR RX CODE DONT USE IN WA $10/20/45 W/INFRTL OR RX CODE DONT USE IN WA OR RX CODE DONT USE IN WA OR RX CODE DONT USE IN WA OR RX CODE DONT USE IN WA OR RX CODE DONT USE IN WA OR RX CODE DONT USE IN WA 10/20/35 RX 06 $15/30/50/100D I E 546 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 3W4 3W5 3W6 3ZE 3ZF 3ZG 3ZH 3ZJ 3ZK 3ZL 3ZM 40A 40B 40C 40D 40E 40F 40G 40H 40I 40J 40K 40L 40M 40N 40O 40P 40Q 40R 40S 40T 40U 40V 40W 40X 40Y 40Z 41A 41B 41C 41D 41E 41F 41G 41H 41I 41J 41K 41L 41M Plan / Benefit Description $15/35/60/200D I E $15/30/50/$100D I E $15/35/60/$200D I E 5/10/20 GR-RX07 10/20/35 GR-RX07 10/20/35 GR-RX07 10/25/55 GR-RX07 10/40/75 GR-RX07 7/20/50% GR-RX07 2/30/60 GR-RX07 10/25/50 GR-RX07 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 547 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 41N 41O 41P 41Q 41R 41S 41T 41U 41V 41W 41X 41Y 41Z 42I 43I 440 44I 45I 46I 47I 48A 48I 49I 4A0 4A1 4AI 4AO 4B0 4B1 4BI 4BO 4C0 4C1 4CI 4CO 4D0 4D1 4E0 4E1 4EI 4EO 4F0 4F1 4FI 4FO 4G0 4G1 4GI 4H0 4H1 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO MCC 3 CENTRAL GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 548 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 4HI 4HO 4I0 4I1 4IA 4IB 4IC 4ID 4IE 4IF 4IG 4IH 4II 4IJ 4IK 4IL 4IN 4IO 4IP 4IQ 4IR 4IS 4IT 4IU 4IV 4IW 4IX 4IY 4IZ 4J0 4J1 4JI 4JO 4K0 4K1 4KI 4KO 4L0 4L1 4LI 4M0 4M1 4MI 4MO 4N0 4N1 4NI 4NO 4O0 4O1 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 549 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 4OA 4OB 4OC 4OD 4OF 4OH 4OI 4OJ 4OK 4OL 4OM 4OO 4OP 4OQ 4OS 4OT 4OU 4OV 4OW 4OX 4OY 4OZ 4P0 4P1 4PI 4PO 4Q0 4Q1 4QI 4QO 4R0 4R1 4RO 4S0 4S1 4T0 4T1 4TI 4U0 4U1 4UI 4UO 4V0 4V1 4VI 4VO 4W0 4W1 4WI 4WO Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 550 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 4X0 4X1 4XI 4XO 4Y0 4Y1 4YI 4YO 4Z0 4Z1 4ZI 4ZO 500 501 502 503 504 505 506 507 508 509 50A 50B 50C 50D 50E 50F 50G 50H 50I 50J 50K 50L 50M 50N 50O 50P 50Q 50R 50S 50T 50U 50V 50W 50X 50Y 50Z 510 511 Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO MANDATED OFFER RIDERS PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO 551 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 512 513 514 515 516 517 518 519 51A 51B 51C 51D 51E 51F 51G 51H 51I 51J 51K 51L 51M 51N 51O 51P 51Q 51R 51S 51T 51U 51V 51W 51X 51Y 51Z 520 521 522 523 524 525 526 527 528 529 52I 530 535 536 537 538 Plan / Benefit Description MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO MANDATED OFFER RIDER PPO RESERVED BENEFIT PPO MANDATED OFFER RIDER PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 552 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 539 53I 540 541 542 543 544 545 546 547 548 549 54I 550 551 552 553 554 555 556 557 558 559 55I 560 561 562 563 564 565 566 567 568 569 56I 570 571 572 573 574 575 576 577 578 579 57I 580 581 582 583 Plan / Benefit Description RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 553 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 584 585 586 587 588 589 58I 590 591 592 593 594 59I 5A0 5A1 5AI 5AO 5B0 5BI 5BO 5C0 5C1 5CI 5CO 5D0 5D1 5E0 5E1 5EI 5F0 5F1 5FI 5FO 5G0 5G1 5GI 5H0 5H1 5HI 5HO 5I0 5I1 5IA 5IB 5IC 5ID 5IE 5IF 5IG 5IH Plan / Benefit Description RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 554 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 5II 5IJ 5IK 5IL 5IN 5IO 5IP 5IQ 5IR 5IS 5IU 5IV 5IW 5IX 5IY 5IZ 5J0 5J1 5JI 5JO 5K0 5K1 5KI 5KO 5L0 5L1 5LI 5M0 5M1 5MI 5N0 5N1 5NI 5NO 5O0 5O1 5O2 5O3 5O4 5O5 5O6 5O7 5O8 5O9 5OA 5OB 5OD 5OF 5OH 5OI Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 555 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 5OJ 5OK 5OL 5OM 5ON 5OO 5OQ 5OS 5OT 5OU 5OV 5OW 5OX 5OY 5OZ 5P0 5P1 5PI 5PO 5Q0 5Q1 5QI 5QO 5R0 5RO 5S0 5T0 5T1 5TI 5U0 5U1 5UI 5UO 5V0 5V1 5VI 5VO 5W0 5W1 5WI 5WO 5X0 5X1 5XI 5XO 5Y0 5Y1 5YI 5YO 5Z0 Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 556 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 5Z1 5Z2 5ZI 5ZO 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 Plan / Benefit Description RESERVED BENEFIT PPO STANDARD 5 PLAN (COBRA) RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 557 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 681 682 683 684 685 686 687 688 689 690 691 692 693 694 6AH 6AL 6BH 6BL 6CD 6DH 6DL 6EH 6EL 6FH 6FL 6GP 6HH 6HL 6HR 6JH 6JL 6JP 6KH 6KL 6KP 6LH 6LL 6MA 6MH 6ML 6NH 6NL 6NM 6PH 6PL 6PM 6QH 6QL 6RH 6RL Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 0/0 HI GR-RX07 0/0 LO GR-RX07 2/30/60 HI GR-RX07 2/30/60 LO GR-RX07 7/14 GR-RX06 2/40 HI GR-RX07 2/40 LO GR-RX07 5/25 HI GR-RX07 5/25 LO GR-RX07 5/65 HI GR-RX07 5/65 LO GR-RX07 8.50/26.45/50% SH6 5/10 HI GR-RX07 5/10 LO GR-RX07 10/20 GR-RX06 5/10/20 HI GR-RX07 5/10/20 LO GR-RX07 8.50/26.70/50% SH6 7/14 HI GR-RX07 7/14 LO GR-RX07 8.50/26.70/50% SH6 7/20/50% HI GR-RX7 7/20/50% LO GR-RX7 10/25%/40% RX-GR06 10/20 HI GR-RX07 10/20 LO GR-RX07 10/20/40 HI GR-RX7 10/20/40 LO GR-RX7 5/15/30 GR-RX06 10/20 HI GR-RX07 10/20 LO GR-RX07 5/15/30 GR-RX06 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 10/20/35 HI GR-RX7 10/20/35 LO GR-RX7 558 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 6SH 6SL 6SR 6TH 6TL 6TP 6UH 6UL 6VM 6WH 6XR 70C 70S 710 711 712 713 714 715 716 717 718 719 71A 71B 71C 71D 71E 71F 71G 71H 71I 71J 71K 71L 71M 71N 71O 71P 71Q 71R 71S 71T 71U 71V 71W 71X 71Y 71Z 720 Plan / Benefit Description 10/25/55 HI GR-RX7 10/25/55 LO GR-RX7 10/20/40 GR-RX06 10/40/75 HI GR-RX7 10/40/75 LO GR-RX7 4.50/14.50/50% SH6 15/25/40 HI GR-RX7 15/25/40 LO GR-RX7 5/5 GR-RX06 10/25/50 HI GR-RX7 15/25/40 GR-RX06 VALUE $25/70% SMALL GROUP VALUE $25/70% SG RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO 559 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 721 722 723 724 725 726 727 728 729 72A 72B 72C 72D 72E 72F 72G 72H 72I 72J 72K 72L 72M 72N 72O 72P 72Q 72R 72S 72T 72U 72V 72W 72X 730 731 732 733 734 735 736 737 738 739 73A 73B 73C 73D 73E 73F 73G Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 560 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 73H 73I 73J 73K 73L 73M 73N 73O 73P 73Q 73R 73S 73T 73U 73V 73W 73X 73Y 73Z 740 741 742 743 744 745 746 747 748 749 74A 74B 74C 74D 74E 74F 74G 74H 74I 74J 74K 74L 74M 74N 74O 74P 74Q 74R 74S 74T 74U Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 561 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 74V 74W 74X 74Y 74Z 750 751 752 753 754 755 756 757 758 759 75A 75B 75C 75D 75E 75F 75G 75H 75I 75J 75K 75L 75M 75N 75O 75P 75Q 75R 75S 75T 75U 75V 75W 75X 75Y 75Z 760 761 762 763 764 765 766 767 768 Plan / Benefit Description RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 562 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 769 76A 76B 76C 76D 76E 76F 76G 76H 76I 76J 76K 76L 76M 76N 76O 76P 76Q 76R 76S 76T 76U 76V 7AQ 7AR 7BD 7BH 7BI 7BL 7BR 7C1 7C2 7CD 7CI 7CM 7CP 7CZ 7DD 7DH 7DL 7DM 7DR 7ED 7EH 7EL 7EM 7ER 7FD 7FH 7FL Plan / Benefit Description RESERVED RX PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO RESERVED PLAN PPO 7/20 GR-RX07 0/0 GR-RX07 7/14 GR-RX07 4/10/20 T1A H GRX7 7/14 I GR-RX07 4/10/20 T1A L GRX7 0/0 FLAT GR-RX07 $25/70% SG $25/70% SG COBRA 7/14 GR-RX07 7/14 I GR-RX07 15/25/40 GR-RX07 5/29/60 N/G SH-RX7 VALUE $25/70% SG COBRA 7/20/30 GR-RX07 4/15/30 T1B H GRX7 4/15/30 T1B L GRX7 15/25/40 GR-RX07 10/10 FLAT GR-RX07 7/7 GR-RX07 4/20/40 T1C H GRX7 4/20/40 T1C L GRX7 3/3 FLAT GR-RX07 10/20 GR-RX07 7/7 C GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 563 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 7FM 7FR 7GD 7GM 7GR 7HH 7HI 7HL 7HR 7JH 7JL 7JM 7JR 7KH 7KI 7KL 7KM 7KR 7LH 7LL 7LM 7LR 7MA 7MH 7MI 7ML 7MR 7NH 7NL 7NM 7O1 7O2 7PH 7PI 7PL 7PM 7PR 7QH 7QI 7QL 7QM 7QR 7RA 7RB 7RC 7RD 7RH 7RL 7RM 7RR Plan / Benefit Description 3/3/3 GR-RX07 10/20 GR-RX07 10/20/30 GR-RX07 5/10 GR-RX07 10/20 GR-RX07 4/15/30 T2A H GRX7 10/20 I GR-RX07 4/15/30 T2A L GRX7 10/20 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/10 GR-RX07 10/10 GR-RX07 4/28/55 T3B H GRX7 10/20/35 I GR-RX07 4/28/55 T3B L GRX7 5/10/20 GR-RX07 10/20/35 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 5/15 GR-RX07 15/25/40 GR-RX07 10/25%/40% GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 10/20/40 GR-RX07 4/25/50 T2C H GRX7 4/25/50 T2C L GRX7 5/15/30 GR-RX07 ALREADY USED ALREADY USED 4/25/50 T2C H GRX7 10/20/40 I GR-RX07 4/25/50 T2C L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 4/20/40 T2B H GRX7 10/20/40 I GR-RX07 4/20/40 T2B L GRX7 5/15/30 GR-RX07 10/20/40 GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 10/20/35 RDS GRX7 10/20 RDS GR-RX07 4/15/30 T2A H GRX7 4/15/30 T2A L GRX7 5/15/30 GR-RX07 15/35/50/50 GR-X07 564 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 7S1 7S2 7SB 7SI 7SR 7SZ 7TH 7TL 7TM 7TR 7UH 7UL 7UM 7UR 7VH 7VL 7VM 7WH 7WI 7WL 7WM 7WR 7XA 7XB 7XC 7XD 7XE 7XF 7XG 7XH 7XJ 7XL 7XM 7XP 7YH 7YI 7YL 7YM 7YR 7ZH 7ZL 7ZM 7ZR 80C 80S 810 811 812 813 814 Plan / Benefit Description $25/70% SG $25/70% SG COBRA 10/25%/40% GR-RX07 10/20/40 I GR-RX07 10/20/40 GR-RX07 VALUE $25/70% SG COBRA 4/28/55 T3B H GRX7 4/28/55 T3B L GRX7 5/5 GR-RX07 10/25/40 GR-RX07 4/28/58 T3C H GRX7 4/28/58 T3C L GRX7 5/5 GR-RX07 15/25/40 GR-RX07 4/25/50 T1D H GRX7 4/25/50 T1D L GRX7 5/5 GR-RX07 4/20/40 T1C H GRX7 15/25/40 I GR-RX07 4/20/40 T1C L GRX7 5/7.50 GR-RX07 15/25/40 GR-RX07 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/25/50 RDS GR-RX7 4/10/20 RDS GR-RX7 4/15/30 RDS GR-RX7 4/20/40 RDS GR-RX7 4/15/30 T1B H GRX7 4/25/50 RDS GR-RX7 4/15/30 T1B L GRX7 7/14 GR-RX07 5/29/60 N/G SH-RX7 4/10/20 T1A H GRX7 15/25/40 I GR-RX07 4/10/20 T1A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 4/25/45 T3A H GRX7 4/25/45 T3A L GRX7 7/14 GR-RX07 15/25/40 GR-RX07 VALUE $20/80% SG VALUE $20/80% SG RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 565 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 82A 82B 82C 82D 82E 82F 82G 82H 82J 82K 82L 82M 82N 82P 82Q 82R 82S 82T 82U 82V 82W 82X 82Y 82Z 830 831 832 833 834 835 836 837 838 839 83A Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15-25/200D T3A AARP GR08 566 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 83B 83C 83D 83E 83F 83G 83H 83J 83K 83L 83M 840 841 842 843 844 845 846 847 848 849 84A 84B 84C 84D 84E 84F 84G 84H 84J 84K 84L 84M 84N 84P 84Q 84R 84S 84T 84U 84V 84W 84X 84Y 84Z 850 851 852 853 854 Plan / Benefit Description 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 10-15/50A T1A AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 5-20/100A T1B AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/200A T1C AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 10-20/750A T2A AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 15-25/130D T2B AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 10-25/150D T2C AARP GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 567 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 855 856 857 858 859 85A 85B 85C 85D 85E 85F 85G 85H 85J 85K 85L 85M 860 861 862 863 864 865 866 867 868 869 881 882 8A8 8AH 8AR 8B8 8BH 8C1 8C2 8CH 8CZ 8DD 8DH 8DR 8ED 8EH 8EM 8ER 8FD 8FH 8GH 8GM 8HD Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-25/200D T3A AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 15-30/220D T3B AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 20-35/250D T3C AARP GR08 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED RX PPO 880 PLAN 880 PLAN 5/29/60NG RX-SH08 0/0 HI C GR-RX07 0/0 C GR-RX07 5/29/60NG RX-SH08 DO NOT USE $20/80% SG $20/80% SG COBRA 2/30/60 HI C GRX07 VALUE $20/80% SG COBRA 7/20/30 C GR-RX07 2/40 HI C GR-RX07 10/10 FLAT C GRX07 7/7 C GR-RX07 5/25 HI C GR-RX07 3/3 FLAT C GR-RX07 10/20 C GR-RX07 7/7 C GR-RX07 5/65 HI C GR-RX07 510 HI C GR-RX07 5/10 C GR-RX07 10/20/30 C GR-RX07 568 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 8HH 8KM 8LH 8LM 8MA 8N8 8NM 8O1 8O2 8PH 8PM 8RH 8RM 8S1 8S2 8SH 8SZ 8TH 8TM 8TR 8UM 8UR 8VM 8WH 8Z1 90C 90S 910 911 912 913 914 915 916 917 918 919 91H 920 921 922 923 924 925 926 927 928 929 92H 930 Plan / Benefit Description DO NOT USE 5/10/20 C GR-RX07 7/20/50% HI C GRX7 5/15 C GR-RX07 10/25%/40% C GRX07 5/29/60G RX-SH08 5/15/30 C GR-RX07 ALREADY USED ALREADY USED 10/20 HI C GR-RX07 5/15/30 C GR-RX07 10/20/35 HI C GRX7 5/15/30 C GR-RX07 $20/80% SG $20/80% SG COBRA 10/25/55 HI C GRX7 VALUE $20/80% SG COBRA 10/40/75 HI C GRX7 5/5 C GR-RX07 10/25/40 C GR-RX07 5/5 C GR-RX07 15/25/40 C GR-RX07 5/7.50 C GR-RX07 10/25/50 HI C GRX7 880 PLAN (COBRA) VALUE $15/90% SG VALUE $15/90% SG RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 15/25/40 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/25/50 HI RX-GR8 RESERVED PPO 569 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 931 932 933 934 935 936 937 938 939 93H 940 941 942 943 944 945 946 947 948 949 94H 950 951 952 953 954 955 956 957 958 959 95H 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20/40 HI RX-GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/20 HI RX-GR08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10/40/75 HI C XGR8 RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 570 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 9AN 9AQ 9AR 9AY 9BE 9BH 9BL 9C1 9C2 9CM 9CZ 9DH 9DR 9EH 9EL 9ER 9FD 9FH 9FL 9GE 9GM 9HD 9HH 9HK 9HL 9HN 9HP 9JH 9JL 9KH 9KL 9KS 9LH 9LL Plan / Benefit Description RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO RESERVED BENEFIT PPO 4/20/40 LO RX-GR08 7/20 RX-GR08 0/0 RX-GR08 4/25/50 HI RX-GR08 7/14 RX-GR08 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 $15/90% SG $15/90% SG COBRA 15/25/40 RX-GR08 VALUE $15/90% SG COBRA 4/15/30 T1B H XGR8 10/10 FLAT C XGR08 4/20/40 T1C H XGR8 4/20/40 T1C L XGR8 10/20 RX-GR08 7/7 C RX-GR08 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 10/20/30 RX-GR08 5/10 RX-GR08 10/20/30 C RX-GR08 4/15/30 T2A H XGR8 4/10/20 RX-GR08 4/15/30 T2A L XGR8 4/15/30 RX-GR08 5/30/45 RX-GR08 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 10/20/35 RX-GR08 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 571 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit 9LM 9LP 9LV 9MA 9MH 9MI 9ML 9MR 9NH 9NL 9NM 9O1 9O2 9PH 9PL 9PZ 9QH 9QL 9RH 9RL 9RP 9RS 9RX 9S1 9S2 9SZ 9TH 9TL 9UH 9UL 9VH 9VL 9VM 9WH 9WI 9WL 9WM 9XH 9XL 9YH 9YL 9ZH 9ZL A1C A1H A1K A1L A1V A1Z A2C Plan / Benefit Description 5/15 C RX-GR08 5/15 RX-GR08 10/20/35 RX-GR08 10/25%/40% RX-GR08 4/20/40 T2B H XGR8 10/20/40 I RX-GR08 4/20/40 T2B L XGR8 10/20/40 RX-GR08 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/15/30 RX-GR08 ALREADY USED ALREADY USED 4/25/50 T2C H XGR8 4/25/50 T2C L XGR8 5/29/60 P RX-GR08 4/20/40 T2B H XGR8 4/20/40 T2B L XGR8 4/15/30 T2A H XGR8 4/15/30 T2A L XGR8 5/15/30 RX-GR08 15/35/50/50 X-GR08 NO RX $15/90% SG $15/90% SG COBRA VALUE $15/90% SG COBRA 4/28/55 T3B H XGR8 4/28/55 T3B L XGR8 4/28/58 T3C H XGR8 4/28/58 T3C L XGR8 4/25/50 T1D H XGR8 4/25/50 T1D L XGR8 5/5 RX-GR08 4/20/40 T1C H XGR8 15/25/40 I RX-GR08 4/20/40 T1C L XGR8 5/7.50 RX-GR08 4/15/30 T1B H XGR8 4/15/30 T1B L XGR8 4/10/20 T1A H XGR8 4/10/20 T1A L XGR8 4/25/45 T3A H XGR8 4/25/45 T3A L XGR8 94-AA-480 PLAN A SNOHOMISH-UNIFORMED (ASO) PLAN A SNOHOMISH-UNIF/COBRA (ASO) 94-AA-480 COBRA BASIC HLT PLN PLUS 572 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit A2L A3C A3H A3L A3Z A4H A4L AA9 AAB AAC AAF AB3 AB5 AB6 AB7 AB8 AB9 AC1 AC2 AC3 AC4 AC5 AC6 AC7 AC8 ACC ACF ACR ACZ AD2 AD7 ADA AE6 AE8 AEF AFA AFS AGB AIC AIZ AJ1 AJ2 AJ3 AJ4 AK1 AK2 AKH AKK AKL AKV Plan / Benefit Description INDIVIDUAL CONV BASIC AA-480 PREFERRED A PLAN COBRA A PLAN AA-480 PREFERRED COBRA PLAN A COBRA PLAN A 5/UNL ACU/CHIRO/NAT/MASS SV 10/100% AMGEN 06 SV 10/80% 06 SV 10/80% 06 CB 10/UNL ACU/CHIRO/NAT/MASS 15/UNL ACU/CHIRO/NAT/MASS 20/UNL ACU/CHIRO/NAT/MASS 25/UNL ACU/CHIRO/NAT/MASS 5/UNL CAM KING COUNTY NOT USED--SEE OLD CODE AP5 $5 CHIRO/ACU/NATUR/MASSAGE $10 CHIRO/ACU/NATUR/MASSAG $15 CHIRO/ACU/NATUR/MASSAG $20 CHIRO/ACU/NATUR/MASSAG $25 CHIRO/ACU/NATUR/MASSAG $3 CHIRO/ACU/NATUR/MASSAG $0 CHIRO/ACU/NATUR/MASSAG $35 CAM AA-480 PREFERRED ADMIN/CONSULTANTS FEE ADMIN. CONTRACT REFUND AA-480 PREFERRED COBRA ADVANTAGE PLAN 3/UNL ACU/CHIRO/NAT/MASS SV 10/100% AMGEN 06 CB 35/UNL ACU/CHIRO/NAT/MASS 0/UNL ACU/CHIRO/NAT/MASS EXECU-FIT SV 10/100% AMGEN 06 ADMINISTRATIVE SERVICE FEE SV 10/100% AMGEN 06 CB DO NOT USE DO NOT USE SV 10/100% SV 10/100% CB SV 10/100% SV 10/100% CB $5/$10 CAM KING COUNTY HMO $10/$20 CAM KNG COUNTY POS KING COUNTY-DUAL-COBRA KING COUNTY POS-DUAL COV KING COUNTY DUAL COVERAGE KG COUNTY POS-DUAL/COBRA 573 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit ALF ALH ALL AM0 AM2 AM3 AM4 AM5 AMC AMD AMF AMG AMH AML AMR AMS AMX AMZ AN1 AN2 AN3 AN5 ANH ANL ANS ANZ AP5 APB APD APF APK APN APV AQK AQV ART AS0 ASA ASH ASL AT1 AT2 AT3 AT4 AT7 ATA ATB ATC ATD ATF Plan / Benefit Description ALREADY USED KNG CNTY B10 DUAL CV COBRA KNG CNTY B10 DUAL COVERAGE SV $10/100% AMGEN CB AMGEN $10/100 AMGEN $10/100 COBRA AMGEN $10/100 AMGEN $10/100 COBRA AMER MED RESPONSE AMMD RSP $20/$300 ADMT SV $10/100% AMGEN SV $10/100% AMGEN KING CNTY POLICE DUAL COBR KING CNTY POLICE DUAL COV AMER MED RESPONSE AMMD RSP $20/$300 ADMT AMMD RSP $20/$300 ADMT CBR AMMD RSP $20/$300 ADMT CBR $5 CHIRO/ACU/NATUR/MASSAGE $10 CHIRO/ACU/NATUR/MASSAG $15 CHIRO/ACU/NATUR/MASSAG RESERVED PEBB ACU/CH/MT PEBB 10/100 DUAL COVER CBR PEBB 10/100 DUAL COVERGE SV 25/80% NSHORE 05 SV 25/80% NSHORE 05 CB PEBB 2005 $10 CAM ALREADY USED ALREADY USED 10/12V 1YR ACU SH07 PEBB POS DUAL COVERAGE 10/12V 1YR ACU SH08 PEBB POS DUAL COV/COBRA KNG CNTY 10/100 POS DUAL KNG CNTY 10/100 POS DUALCB RESERVED ART CODE ALLERGY SERUM 100% ADMINISTRATIVE FEE (ASO) CITY OF SEATTLE (COBRA) CITY OF SEATTLE SV $10-$15/$100A AT&T SV $10-$15/$100A AT&T CB SV $10-$15/$100A AT&T SV $10-$15/$100A AT&T CB ATW-STD SH-WL07 SV 10-15/100A AT&T 06 SV 10-15/100A AT&T 06 AT & T CORP SV 10-15/100A AT&T 06 CB SV 15/100% VERIZON 06 574 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit ATH ATJ ATK ATL ATM ATP ATQ ATT ATU ATV ATX ATZ AW5 AW6 AW7 AW8 AWC AWF AZ2 AZC AZG AZM AZT B2A B2B B2C B2D B2E B2F B2G B2H B2J B2P B2R B3A B3B B3C B3D B3E B3F B3G B3H B3J B3P B3R B4A B4B B4C B4D B4E Plan / Benefit Description CITY OF SEATTLE-DUAL-COBRA SV 15/100% VERIZON 06 CB SV 10-15/100A AT&T 06 CB CITY OF SEATTLE-DUAL SV 15/100% VERIZON 06 ATW-PLUS SH-WL07 ATW ENHANCED SH08 AT& T CORP ATW-PLUS WL-SH08 ATW-STD WL-SH08 SV 15/100% VERIZON 06 CB AT & T CORP COBRA SV 10/100% 06 SV 10/100% 06 CB SV 10/100% 06 SV 10/100% 06 CB WASH BASIC HLTH-MEDICAID19 ALREADY USED STANDARD 10 PLAN (COBRA) AMER MED RESPONSE COBRA SV $10/100% AMGEN CB AMER MED RESPONSE COBRA AT& T CORP COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPOR RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 575 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit B4F B4G B4H B4J B4P B4R B5A B5B B5C B5D B5E B5F B5G B5H B5J B5P B5R B6A B6B B6C B6D B6E B6F B6G B6H B6J B6R B7A B7B B7C B7D B7E B7F B7G B7H B7J B7P B7R B8A B8B B8C B8D B8E B8F B8G B8H B8J B8P B8R B9A Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED PPO 576 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit B9B B9C B9D B9E B9F B9G B9H B9J B9P B9R BA1 BA2 BAA BAC BC8 BFF BJ1 BJ2 BJ3 BJ4 BJ5 BJ6 BJ7 BJ8 BK5 BK6 BOE BOF BOG BOH BP2 BP3 BP4 BP5 BP6 BP7 BP8 BP9 BPA BPC BPD BPE BPF BPG BPH BPJ BPK BPL BPM BPN Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO BASIC PLAN BASIC PLAN SV 10/250A 06 SV 10/250A 06 CB SMI/MH/CD 25/100%/45V VEBA SV 15-25/250A BOEING 08 SV $10/80% SV $10/80% CB SV $10/80% SV $10/80% CB SV 10/80% SG SV 10/80% SG CB SV 10/80% SG SV 10/80% SG CB ALREADY USED ALREADY USED SV $15-$25/$250A VEBA SV $15-$25/$250A VEBA CB SV $15-$25/$250A VEBA SV $15-$25/$250A VEBA CB RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 577 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit BPP BPQ BPR BPS BPU BPV BPW BPX BPY BPZ BR2 BR3 BR4 BR5 BR6 BR7 BR8 BR9 BRC BRD BRE BRF BRJ BRR BRW BRZ BTB BTE BTF BU1 BU2 BU3 BU4 BU5 BU6 BU7 BU8 BU9 BUC BUD BUE BUF BUG BUH BUI BUJ BUK BUL BUM BUN Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO SV 20/250A BRE PROPERTS SV 20/250A BRE PROPERTS CB SV 20/250A BRE PROPERTS SV 20/250A BRE PROPERTS CB SV 20/250A BRE PROP 06 SV 20/250A BRE PROP 06 CB SV 20/250A BRE PROP 06 SV 20/250A BRE PROP 06 CB SV 15-25/250A BOEING 08 SV 15-25/250A BOEING 08 CB SV 15-25/250A BOEING 08 CB RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO 578 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit BVA BVB BVC BVD BVE BVK BVL BVN BW5 BW6 BW7 BW8 BX2 BX3 BX4 BX5 BX6 BX7 BX8 BX9 BXA BXB BXC BXD BXE BXF BXG BXH BXJ BXK BXL BXM BXN BXP BXR BXS BXT BXU BXV BXW BXX BXY BXZ BYA BYB BYC BYD BYE BYF BYG Plan / Benefit Description SV 15-25/250A BOEING 06 SV 15-25/250A BOEING 06 CB SV 15-25/250A BOEING 06 SV 15-25/250A BOEING 06 CB 15/100A BOEING VEBA GR07 15/100A BOEING VEBA GR07 15 BO VEBA NON-AARP GR08 15 BO VEBA NON-AARP GR08 SV 10/80% 06 SV 10/80% 06 CB SV 10/80% 06 SV 10/80% 06 CB RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO 579 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit BYH BYJ BYK BYL BYM BYN BYP BYR BYS BZ1 BZ2 BZ3 BZ4 BZ5 BZ6 BZ7 BZ8 BZ9 BZA BZB BZC BZD BZE BZG BZH BZJ BZK BZL BZM BZN BZP BZR BZS BZT BZV BZW BZX BZY BZZ C0C C0Z C1C C1H C1L C1Z C27 C2C C2H C2L C2Z Plan / Benefit Description RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO BASIC PLAN (COBRA) BASIC PLAN (2) COBRA RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO RESERVED RX PPO CC SCHOOL DIST $0/100% CC SCHOOL DIST $0/$100 CBR 94-BA-480 PLAN B/3 COBRA PLAN B/3 94-BA-480 COBRA SC 90 ELIGIBILITY ONLY BA-480 STANDARD B/3 PLAN COBRA B/3 PLAN BA-480 STANDARD COBRA 580 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit C3C C3H C3L C3Z C6A C6X C6Z C70 C71 C72 C7A C7D C7E C7F C7G C7H C7J C7K C7L C7M C7P C7R C7S C7U C7W C7Y C7Z C80 C81 C82 C8Z C90 C91 C92 C9Z CA5 CAB CAD CBC CBE CBG CBZ CCA CCD CCH CD2 CD5 CDN CF1 CF2 Plan / Benefit Description CC SCHOOL DIST $3/100% PLAN B/3 COBRA PLAN B/3 CC SCHOOL DIST $3/100$ CBR SV 20-40/400D CKE 06 SV 20-40/400D CKE 06 AB SV 20-40/400D CKE 06 CB VALUE $25/70% $25/70% $25/70% COBRA 5/12V 1YR GR-CH07 50%/$250MAX 1YR GR-CH07 10/12V 1YR GR-CH07 10/20V 1YR GR-CH07 10/30V 1YR GR-CH07 15/12V 1YR GR-CH07 15/20V 1YR GR-CH07 0/20V 1YR GR-CH07 15/30V 1YR GR-CH07 20/12V 1YR GR-CH07 5/10V 1YR GR-CH07 10/1500MAX GR-CH07 30/12V 1YR GR-CH07 5/20V 1YR GR-CH07 5/30V 1YR GR-CH07 5/40 1YR GR-CH07 VALUE $25/70% COBRA VALUE $20/80% $20/80% $20/80% COBRA VALUE $20/80% COBRA VALUE $15/90% CLARK $15/90% $15/90% COBRA VALUE $15/90% CLARK COBRA $5G/$10B SV 15/200D 06 SV 15/200D 06 CB BA-480 STANDARD SP 25/80% COM MEN HL 06 SP 25/80% COM MEN HL 06 CB BA-480 STANDARD COBRA SP 25/80% COM MEN HL 06 SP 25/80% COM MEN HL 06 CB CORE CHIRO CHEMICAL DEPEND. - RIDER 2 CHEM. DEP. RIDER 2 CHEMICAL DEPENDENCY CUSTOM RESERVED FOR RX PPO RESERVED FOR RX PPO 581 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit CF3 CFA CFD CFE CFF CFQ CGG CGI CGL CGO CGP CGS CGV CGX CH0 CH1 CH2 CH3 CH4 CH5 CH6 CH7 CH8 CHA CHB CHC CHD CHE CHF CHG CHH CHJ CHK CHN CHQ CHT CHU CHW CJ1 CJ2 CJ3 CJ4 CJ5 CJ6 CJ7 CJ8 CJ9 CMO CP5 CPA Plan / Benefit Description RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO SV 15-25/100A COMCST 07 CAREGIVER-SH GOLD CAREGIVER-SH INDIV CAREGIVER LITE SH06 CHIRO RET $10/$1500 MAX CAREGIVER PROGRAM CAREGIVER PROGRAM CAREGIVER CG-GR08 CAREGIVER ENHANCED CHIROPRACTIC CARE PEBB - CHIROCARE CHIROPRACTIC C/3 CHIROPRACTIC C/5 CHIROPRACTIC C/10 CHIROPRACTIC C/15 CHIROPRACTIC C/20 CHIRO B POS PEBB DUAL COVERAGE $0 CHIR CHIROPRACTIC A (CORE) CHIROPRACTIC B CHIROPRACTIC C/0 CHIROCARE $10 CHIRO - FEDS CHIRO A (FEDS) $10/40 VISITS CAL YR USWST $15 $1500 ANNUAL MAX FEDS CHIRO $10/30 VISITS ALREADY USED CHIROPRACTIC - CUSTOM 15/UNLMTD CH06 15/30V FEDS CH06 10/12V 1YR SH-CH07 10/12V 1YR SH-CH08 SV 15/80% SV 15/80% CB SV 15/80% SV 15/80% CB ALREADY USED ALREADY USED FEDS 15/UNL ACU/CH/NAT/MAS OOA ACU/CHIRO/NAT/MASS 07 30/UNL ACU/CHIRO/NAT/MASS CAM OUT-OF-AREA $5G/$15BR RETIREE RESERVED PFFS 582 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit CPO CPS CR3 CR4 CR5 CR6 CRG CRX CRY CS9 CSE CT6 CTM CW5 CW6 CW7 CW8 D00 D1C D1H D1K D1L D1V D1Z D2C D2H D2K D2L D2V D2Z D3H D3K D3L D3V D6L D6M D6Q D6R D6T D6U D6V D7P D7Y D8A D8E D8F DAM DAP DBA DBC Plan / Benefit Description PEBB CH RET 50%/$250MAX1YR $30 CHIRO/ACU/NATUR/MASSAG GRP RET CHIRO $5/12VISITS GRP RET CHIRO $10/12VISITS GRP RET CHIRO $15/12VISITS GRP RET CHIRO $20/12VISITS CUSTOM PPO RESERVED FOR RX PPO RESERVED FOR RX PPO ALREADY USED ALREADY USED 30/12V GR-CH07 SH-CLARK TR-MET RET GRP $5 SV 15/80% 06 SV 15/80% 06 CB SV 15/80% 06 SV 15/80% 06 CB DURABLE MED EQUIP $0 94-CA-480 PLAN B/5 COBRA 100/5 PLAN POS PLAN B/5 100/5 PLAN POS (COBRA) 94-CA-480 COBRA CA-480 B/5 PLAN COBRA 100/5 POS PLAN B/5 PLAN 100/5 POS PLAN COBRA 14-480 COBRA PLAN B/5 COBRA POS PLAN 100/5 PLAN B/5 POS PLAN 100/5 COBRA DUAL COVERAGE STD 06 DUAL COVERAGE STD 06 CB DUAL COVERAGE MC STD 06 DUAL COV MC STD 06 COBRA DUAL COVERAGE MC STD 06 DUAL COV MC STD 06 COBRA DENTAL - VISION GR06 CA-480 POS(IN-NETWK1&2) CA-480 POS(IN-NETWK1&2)CBR DELUXE OPTION DN-SH08 $20 469 DN-SH08 $0 466 DN-SH08 DUAL COVERAGE MC STANDARD DUAL COVERAGE POS STANDARD 100%/70% DISCOUNT GR-DN07 CA-480 583 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit DBO DBZ DC1 DC2 DC3 DC4 DCE DCH DCL DCN DD6 DDG DDK DDP DDR DDS DDV DEH DEL DIR DJ1 DJ2 DJ3 DJ4 DK1 DK2 DK3 DK4 DKH DKK DKL DLH DLL DM2 DM4 DMA DMH DMK DML DMV DMZ DN1 DN2 DN3 DNK DNP DNT DNV DNY DP1 Plan / Benefit Description DNTL DISCNT PRGRM - WSHNGT CA-480 COBRA PREMIER $5/100% PREMIER $5/100% COBRA PREMIER $5/100% PREMIER $5/100% COBRA SV 15/90% 06 B/5 CITY OF SEATTLE COBRA B/5 PLAN-CITY OF SEATTLE SV 15/90% 06 CB $0 466 SH-DN06 DENTAL DISCOUNT RETIREES DOMINICAN NETWORK POS DENTAL DISCOUNT PROGRAM DENTAL DISCOUNT RETIREES DENTAL DISCOUNT PROGRAM DOMINICAN NETWORK POS COBR B/5 SEATTLE SPMA COBRA B/5 CITY OF SEATTLE SPMA DUMMY-USED FOR VRU CODING SV 10/250A SV 10/250A CB SV 10/250A SV 10/250A CB PREMIER $5/100% PREMIER $5/100% COBRA PREMIER $5/100% PREMIER $5/100% COBRA KING COUNTY POLICE COBRA DUMMY KING COUNTY POLICE SEATTLE LIBRARY COBRA CITY OF SEATTLE LIBRARY ALREADY USED RESERVED DUAL COVERAGE MC STANDARD KNG CNTY POLICE B5 COBRA 100/5 CUSTOM POS PLAN KNG CNTY POLICE CUSTOM B5 100/5CUSTOM POS PLAN COBRA DUAL COVERAGE MC STD COBRA DENTAL PLAN (PACIFIC MED) RESERVED PPO GRP RET DEN RESERVED PPO GRP RET DEN NORTHWEST HOSP POS (100/5) INDEMNITY DENTAL DENTAL PLAN NORTHWEST HOSP POS-COBRA DELUXE OPTION SH-DN07 DEPENDENT LIFE BENE 584 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit DP2 DP3 DP4 DP5 DPA DPC DPH DPK DPL DPM DPN DPO DPP DPV DPY DPZ DQ6 DQP DQY DRH DRL DSH DSL DTC DW5 DW6 DW7 DW8 DZ2 DZM DZP EA3 EA5 EAA EAD EAP ECE ECN ECP EV1 EV2 EV3 EV4 EW5 EW6 EW7 EW8 F01 F02 F03 Plan / Benefit Description WA PEBB PENDING PLAN CLARK PEBB PENDING PLAN SV 10/150D PEBB 2005 SV 10/150D PEBB 2005 DUAL COVERAGE POS STANDARD DOMESTIC PARTNER COVERAGE SEATTLE POLICE COBRA PEBB SH PEND CITY OF SEATTLE POLICE PEBB SH PEND PEBB SH PENDING EFF 1-99 PEBB SH PENDING 1-99 POS-CA-480 PEBB SH PEND COBRA POS-CA-480 COBRA DUL COVERAGE POS STD COBRA $20 469 SH-DN06 CA-480 POS (IN-NETWK1&2) CA-480 POS(IN-NETWK1&2)CBR RED LIONS HOTEL (B5) COBRA RED LIONS HOTEL (B5) CITY OF SEATTLE (COBRA) CITY OF SEATTLE INACTIVE PLAN CODE SV 10/250A 06 SV 10/250A 06 CB SV 10/250A 06 SV 10/250A 06 CB ADVANTAGE PLAN COBRA DUAL COVERGAE MC STANDARD DUAL COVERAGE POS STD CBRA EAP-3 VISITS (PBHI) EAP-5 VISITS (PBHI) SV 15/80% 06 SV 15/80% 06 CB PBHI - EAP BENEFIT ALREADY USED ALREADY USED ALREADY USED SV $15/80% EVERETT SD SV $15/80% EVERETT SD CB SV 15/80% EVERETT SD 06 SV 15/80% EVERETT SD 06 CB SV 15/200D 06 SV 15/200D 06 CB SV 15/200D 06 SV 15/200D 06 CB LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO 585 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit F04 F05 F06 F07 F08 F09 F10 F11 F12 F13 F14 F15 F16 F17 F18 F19 F1C F1H F1K F1L F1P F1V F1Y F1Z F20 F21 F22 F23 F24 F25 F26 F27 F28 F29 F2C F2H F2K F2L F2V F2Z F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 Plan / Benefit Description LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO $10G/$10B LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO 94-DA-480 PLAN B/10 COBRA 100/10 PLAN POS PLAN B/10 94-DA-480 (OPTION) 100/10 PLAN POS (COBRA) 94-DA-480 (OPTION) COBRA 94-DA-480 COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO DA-480 STANDARD 10 PLAN B/10 PLAN COBRA 100/10 POS PLAN B/10 PLAN 100/10 POS PLAN COBRA DA-480 STND 10 PLAN COBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO 586 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit F3H F3K F3L F3S F3V F3X F40 F41 F42 F43 F44 F45 F46 F47 F48 F49 F4H F4L F50 F51 F52 F53 F54 F55 F56 F57 F58 F59 F5H F5L F5M F5N F60 F6H F6L F7P F7Y F9C F9S F9X F9Z FAA FAB FAC FAD FAE FAF FAH FAK FAL Plan / Benefit Description PLAN B10 COBRA POS PLAN 100/10 PLAN B10 PLAN B10 SG PRE-EX POS PLAN 100/10 COBRA PLAN B10 SG PRE-EX CBRA LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO BOEING CUSTOM 1-00 COBRA BOEING CUSTOM 1-00 LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO LIMITED FEE SCHEDULE PPO SEATTLE SCHOOL CSTM 1-00CB SEATTLE SCHOOL CUSTOM 1-00 SEATTLE SCHOOL DIST SEATTLE SCHOOL DIST LIMITED FEE SCHEDULE PPO B/10 PLAN VENATOR COBRA B/10 PLAN VENATOR DA-480 POS(IN-NETWK3&4) DA-480 POS(IN-NETWL3&4)CBR DA-480 SMALL GROUP DA-480 SG PRE-EX DA-480 SG PRE-EX CBRA DA-480 SMALL GROUP COBRA SV 15-30/250A 06 SV 25/90/200A SSDST 05 SV 15-30/250A 06 CB SV 10-15/250A FIDLTY 06 ALREADY USED SV 25/90/200A SSDST 05 CB ALREADY USED SV 10-15/250A FIDLTY 06 CB SV 25/240A FIDLTY 07 587 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit FAM FAR FAS FB6 FBB FBC FBR FBZ FC1 FC2 FC3 FC4 FC5 FC6 FC7 FC8 FC9 FCA FCB FCE FCF FCI FCJ FCL FCM FCN FD5 FD6 FD7 FDA FDD FDE FDF FDG FF1 FF2 FF3 FF4 FFA FFC FFF FFG FFK FFL FFN FFP FFS FFV FH6 FHG Plan / Benefit Description ALREADY USED FARMERS INS SV 25/240A FIDLTY 07 CB SV 15-30/200D FEDS 06 FITNESS BENEFIT SH06 DA-480 STANDARD 10 PLAN FARMERS $15/$30/$250A DA-480 STANDARD 10 PLAN CB PREMIER $10/100% PREMIER $10/100% COBRA PREMIER $10/100% PREMIER $10/100% COBRA PREMIER $10/100 SG PREMIER $10/100 SG COBRA PREMIER $10/100 SG PREMIER $10/100 SG COBRA RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX RESERVED FOR PPO RX SV $15-$45/$250D FEDS ALREADY USED ALREADY USED SV $15-$45/$250D FEDS SV 35/240A FID IN SV 06 SV 35/240A FID IN SV 06 SV 35/240A FID IN SV 06 CB SV 35/240A FID IN SV 06 CB FIREMAN FUND FIREMAN FUND COBRA FIREMAN FUND FIREMAN FUND COBRA SV 10-15/250A FIDLTY 06 SV 25/240A FIDLTY 07 ADMINISTRATIVE RETENTION ALREADY USED SV 10-15/250A FIDLTY 06 CB FEHB-FED EMPLOYEES SV 25/240A FIDLTY 07 CB POS-DA-480 FITNESS SH/GR-WL07 FITNESS SH/GR-WL08 SV 15-30/200D FEDS 06 ALREADY USED 588 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit FHH FHK FHL FHM FHV FI1 FI2 FI3 FI4 FID FIM FIZ FJB FJM FJN FK1 FK2 FK3 FK4 FK5 FK6 FK7 FK8 FKB FKH FKK FKL FKV FLH FLK FLL FM6 FMC FMH FML FMM FMN FMZ FN1 FN2 FN3 FN4 FNA FNB FND FNE FNZ FP1 FP2 FP3 Plan / Benefit Description HARSCH INVEST. B/10 COBRA CUSTOM PCW POS PLAN HARSCH INVESTMENTS B/10 FEDERAL EMPLOYEES HEALTH CUSTOM PCWA POS PLAN COBRA SV 15/200D SV 15/200D CB SV 15/200D SV 15/200D CB FEDS INDEMNITY DENTAL 2001 FEDERAL EMPLOYEES PLAN1-99 DB-1000 20% SMALL GRP COBR SV 15-30/200D FEDS 08 FEDS 2001 FEDS 2003 PREMIER $10/100% PREMIER $10/100% COBRA PREMIER $10/100% PREMIER $10/100% COBRA PREMIER $10/100% SG PREMIER $10/100% SG COBRA PREMIER $10/100% SG PREMIER $10/100% SG COBRA SV 15-30/200D FEDS 08 PLAN B10 KING COUNTY COBRA 100/10 KING COUNTY POS PLAN B10-KING COUNTY 100/10 KING CTY POS COBRA KING COUNTY 10/100 POS CBR KING COUNTY 10/100 POS DUMMY ALREADY USED ALREADY USED KNG CNTY CUSTOM B10 COBRA KNG CNTY CUSTOM B10 SV $15-30/250A FARMERS SV $15-30/250A FARMERS SV $15-30/250A FARMERS CB FIDELITY NATL FINANCIAL FIDELITY NAT FINANCE COBRA FIDELITY NATL FINANCIAL FIDELITY NATL FINANCE COBR SV 10-15/250A FIDELITY SV 10-15/250A FIDELITY CB SV 10-15/250A FIDELITY SV 10-15/250A FIDELITY CB SV $15-30/250A FARMERS CB POS $10/100%/75% POS $10/100%/75% COBRA POS $10/100%/75% 589 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit FP4 FPA FPB FPC FPD FPK FPP FPV FPY FQP FQY FRA FRS FRZ FSK FSV FW5 FW6 FW7 FW8 FZR G1C G1P G1Y G1Z G2C G2R G2Z GAA GAB GBC GBZ GCE GCN GCP GFI GFQ GFU GFV GFW GFY GG6 GG7 GG9 GGE GGN GGP GHI GHQ GHU Plan / Benefit Description POS $10/100%/75% COBRA POS $10/100%/75% POS $10/100%/75% COBRA POS $10/100%/75% POS $10/100%/75% COBRA PACIFICARE EMP POS(100/10) POS-DA-480 PCC EMP POS (100/10) COBRA POS-DA-480 COBRA DA-480 POS(IN-NETWK3&4) DA-480 POS(IN-NETWK3&4)CBR RISK CHARGE - AGGREGATE RISK CHARGE - SPECIFIC FARMERS $15/$30/$250A CBRA STEVENS HIGH (ASO) STEVENS HIGH (ASO) COBRA SV 20/300D 06 SV 20/300D 06 CB SV 20/300D 06 SV 20/300D 06 CB FARMERS INS COBRA 94-EA-480 94-EA-480 (OPTION) 94-EA-480 (OPTION) COBRA 94-EA-480 COBRA EA-480 DUMMY EA-480 COBRA SP 20/80% 06 SP 20/80% 06 CB EA-480 EA-480 COBRA 15-30 CENTRAL C SH06 EPO 15-30 CENTRAL C SH06 15-30 CENTRAL C SH06 ODP ARP MCC 1 CE EP-PL SH08 ARP MCC 1 CE PP-PL SH08 ARP MCC 1 CE PP SH08 ARP MCC 1 CE PLUS SH08 ARP MCC 1 CE SH08 ARP MCC 1 CE EP SH08 MCC 1 CE PP-PL SH07 MCC 1 CE EP-PL SH07 MCC 1 CE PLUS SH07 MCC 1 CE EP SH07 MC COMP 1 CE SH07 MCC 1 CE PP SH07 ARP MCC ES CE EP-PL SH08 ARP MCC ES CE PP-PL SH08 ARP MCC ES CE PP SH08 590 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit GHV GHW GHY GJ1 GJ2 GJ6 GJ7 GJ9 GJE GJI GJN GJP GJQ GJU GJV GJW GJY GME GMN GMP GN6 GN7 GN9 GNE GNN GNP GRI GRQ GRU GRV GRW GRY GSC GSZ GVE GVN GVP GW5 GW6 GW7 GW8 H01 H02 H03 H04 H05 H06 H07 H08 H09 Plan / Benefit Description ARP MCC ES CE PLUS SH08 ARP MCC ES CE SH08 ARP MCC ES CE EP SH08 ALREADY USED ALREADY USED MCC ESS CE PP-PL SH07 MCC ESS CE EP-PL SH07 MCC ESS CE PLUS SH07 MCC ESS CE EP SH07 ARP MCC 3 CE EP-PL SH08 MC COMP ESS CE SH07 MCC ESS CE PP SH07 ARP MCC 3 CE PP-PL SH08 ARP MCC 3 CE PP SH08 ARP MCC 3 CE PLUS SH08 ARP MCC 3 CE SH08 ARP MCC 3 CE EP SH08 10-20 CENTRAL M SH06 EPO 10-20 CENTRAL M SH06 10-20 CENTRAL M SH06 ODP MCC 3 CE PP-PL SH07 MCC 3 CE EP-PL SH07 MCC 3 CE PLUS SH07 MCC 3 CE EP SH07 MC COMP 3 CE SH07 MCC 3 CE PP SH07 ARP MCC 3 CE EP-PL SH08 ARP MCC 3 CE PP-PL SH08 ARP MCC 3 CE PP SH08 ARP MCC 3 CE PLUS SH08 ARP MCC 3 SO SH08 ARP MCC 3 CE EP SH08 94-EA-480 (SWMC) 94-EA-480 (SWMC) 5-15 CENTRAL V SH06 EPO 5-15 CENTRAL V SH06 5-15 CENTRAL V SH06 ODP SV 20/500D 06 SV 20/500D 06 CB SV 20/500D 06 SV 20/500D 06 CB DOMESTIC PARTNERSHIP PPO VISION CARE BENEFIT PPO FAMILY PLANING BENEFIT PPO 24/HOUR HEALTH INFO PPO HEARING AID BENEFIT PPO MENTAL NON-SMI PPO 90/70 RESERVED FOR PPO PRODUCT MENTAL NON-SMI PPO 90/50 MENTAL NON-SMI PPO 80/60 591 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit H10 H11 H12 H13 H14 H15 H16 H17 H18 H19 H1Z H20 H21 H22 H23 H24 H25 H26 H27 H28 H29 H2Z H30 H31 H32 H33 H34 H35 H36 H37 H38 H39 H3Z H40 H41 H42 H43 H44 H45 H46 H47 H48 H49 H50 H51 H52 H53 H54 H55 H56 Plan / Benefit Description MENTAL NON-SMI PPO 80/50 MENTAL NONSMI INDEMNITY 80 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO PREF $10/$20/$100 COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO PREF $15/$30/$250 COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO VESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO $20/$40/$400A COBRA RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 592 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit H57 H58 H59 H60 H61 H62 H63 H64 H65 H66 H67 H68 H69 H6P H70 H71 H72 H73 H74 H75 H76 H77 H78 H79 H80 H81 H82 H83 H84 H85 H86 H87 H88 H89 H8A H8B H8D H8O H90 H91 H92 H93 H94 H95 H96 H97 H98 H99 HA1 HA2 Plan / Benefit Description RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 15-25/100A GR06 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO 0/500A 3YRS PL HA-SH08 0/1300A 3YRS DX HA-SH08 0/800A 3YRS DX HA-SH08 0/500A 3YRS HA-GR08 RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO RESERVED FOR PPO PEBB - HEARING AIDS HEARING AIDE $300 593 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit HA3 HA4 HA5 HAJ HAN HAO HAZ HB1 HB2 HB3 HBA HBC HBZ HCE HCN HCP HCZ HDE HEP HEQ HER HES HFQ HFR HG1 HG2 HG3 HG4 HGO HHE HJ1 HJ2 HJ3 HJ4 HK1 HK2 HK3 HK4 HM1 HM2 HM3 HMA HMB HMC HME HMN HMP HOA HOE HOI Plan / Benefit Description HEARING AID $250 ALLOW. HEARING AID $500 EVERY 36M HEARING $500 PER EAR/24MO HEARING AID $500 EVERY 3YR 300A/24M GR-VN07 HEARING AID BENEFIT PREF $10/$20/$100 COBRA RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT RESERVED FOR PPO PRODUCT SV 20/300D 06 SV 20/300D 06 CB PREF $15/$30/$250 COBRA ALREADY USED ALREADY USED ALREADY USED $20/$40/$400A COBRA 300A 2YRS HA-GR08 SV 20-40/500A HP 07 SV 20-40/500A HP 07 CB SV 20-40/500A HP 07 SV 20-40/500A HP 07 CB ALREADY USED ALREADY USED SV 10-20/100A SV 10-20/100A CB SV 10-20/100A SV 10-20/100A CB HRING AID RET $1000MAX/3YR 500A 3YRS HA-GR08 SV 15-30/250A SV 15-30/250A CB SV 15-30/250A SV 15-30/250A CB SV 20-40/400A SV 20-40/400A CB SV 20-40/400A SV 20-40/400A CB PREF $10/$20/$100 PREF $15/$30/$250 $20/$40/$400A PREF $10/$20/$100 PREF $15/$30/$250 $20/$40/$400A ALREADY USED ALREADY USED ALREADY USED RESERVED HEARING PFFS RESERVED HEARING PFFS RESERVED HEARING PFFS 594 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit HP1 HP2 HP3 HP4 HP5 HPA HPB HPC HPD HPE HPF HPG HPH HPJ HPN HPO HPP HPS HPZ HQC HR2 HR3 HRB HRD HRF HRG HRP HRY HTC HW5 HW6 HW7 HW8 HZ2 I01 I02 I03 I06 I07 I1C I1Z I2C I2Z I40 I50 I60 I81 I82 IBC IBZ Plan / Benefit Description HP $15/$300A 550 PLAN HP $15/$300A COBRA HP $15/$300A HP $15/$300A COBRA SV $15-$30/$500A HP SV $15-$30/$500A HP CB SV $15-$30/$500A HP SV $15-$30/$500A HP CB RESERVED PFFS SV 15-30/500A HP 06 20-40/500A HP GR07 20-40/500A HP GR07 SV 15-30/500A HP 06 20-40/500A HP NO-AARP GR08 PEBB HRING AID $300MAX3YRS 20-40/500A HP NO-AARP GR08 SV 15-30/500A HP 06 CB SV 15-30/500A HP 06 CB $300 MAX 3YRS PEBB HA-GR08 HRING AID $500 ALLOWANCE HRING AID $300 ALLOWANCE 0/500A 3YRS SH-HA07 0/800A 3YRS DX SH-HA07 ALREADY USED SH INDIV. HEARING 0/500A 3YRS PL SH-HA07 0/1300A 3YRS DX SH-HA07 500A 2YRS HA-GR08 SV 20/250A 06 SV 20/250A 06 CB SV 20/250A 06 SV 20/250A 06 CB 550 PLAN COBRA INDEMNITY COVERAGE PLAN INDEMNITY PLAN HIGHLINE INDEMNITY ASO OOA SUBSCRIBER PLAN I OOA SUBSCRIBER PLAN II 94-CB-800 94-CB-800 COBRA CB-800 CB-800 COBRA SIGNATUREVALUE 40C SIGNATUREVALUE 50C SIGNATUREVALUE 60C IND. CONV. PLAN - 880 IND. CONV. PLAN - 880 CB-800 CB-800 COBRA 595 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit IC2 ICI ICP ID4 ID5 ID6 IGJ IGL IOA IOB IOC IOD IOE IPI IPZ IS1 IUH IWH IZ1 IZ2 IZ3 IZ6 IZ7 IZA IZB IZC IZD IZL J1K J1V J2K J2V JAA JAJ JJ1 JJ2 JJB JJF JJN JW5 JW6 JW7 JW8 K1C K1H K1K K1L K1V K1Y K1Z Plan / Benefit Description INDIVIDUAL CONVERSION 7/90 SV 15-30/100% ICI PNTS SV 15-30/100% ICI PNTS CB SIGNATUREVALUE 40C SIGNATUREVALUE 50C SIGNATUREVALUE 60C SV 25-35/450A INTRPUB07 SV 25-35/450A INTRPUB07 CB INDEMNITY- OUT OF AREA INDEMNITY OUT-OF-AREA INDEMNITY SG OOA INDEMNITY SG OOA POS - OUT OF AREA SV 15-30/100% ICI PNTS SV 15-30/100% ICI PNTS CB IND. CONV. - SHARE SV 25-35/450A INTRPUB07 SV 25-35/450A INTRPUB07 CB INDEMNITY COVERAGE COBRA INDEMNITY-COBRA HIGHLINE INDEMNITY ASO OOA SUBSCRIBER PLAN I COBR OOA SUBSCRIBER PLAN II CBR INDEMNITY-OUT OF AREA COBR INDEMNITY OUT-OF-AREA CBRA INDEMNITY SG OOA COBRA INDEMNITY SG OOA COBRA ERRONEOUS ENTRY HIGHLINE COMM. HOSP. (ASO) HIGHLINE HOSP. (ASO) COBRA SNOHOMISH-NONUNIF. ASO SNOHOMISH-NONUNI/COB (ASO) SV 20/250A 06 SV 20/250A 06 CB ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED SV 10-20/100A 06 SV 10-20/100A 06 CB SV 10-20/100A 06 SV 10-20/100A 06 CB 94-DB-1000 PREFERRED $10 (COBRA) 80/10 POS PLAN PREFERRED $10 80/10 POS PLAN COBRA ALREADY USED 94-DB-1000 COBRA 596 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit K2C K2H K2K K2L K2P K2V K2Y K2Z K3H K3K K3L K3V K4C K4H K4K K4L K4S K4V K4X K4Z K5C K5Z K7P K7Y K8P K8Y K9C K9P K9S K9X K9Y K9Z KA2 KA3 KA4 KA5 KA6 KA7 KA8 KA9 KAA KAB KAC KAP KAS KAX KAY KAZ KB2 KB3 Plan / Benefit Description DB-1000 IPGB PLAN D (COBRA) 90/10 POS PLAN PLAN D 94-DB-1000-OPTION 90/10 POS PLAN COBRA 94-DB-1000-OPTION DB-1000 IPGB COBRA D PLAN COBRA POS PLAN 90/10 D PLAN POS PLAN 90/10 COBRA DB-1000 SHARE PLAN PLAN D COBRA POS PLAN 80/10 PLAN D PLAN D SG PRE-EX POS PLAN 80/10 COBRA PLAN D SG PRE-EX CBRA DB-1000 SHARE PLAN COBRA 00-DB-1000 00-DB-1000 COBRA DB-1000 POS (IN-NETWK5) DB-1000 POS(IN-NETWK5) CBR 00-DB 1000 POS(IN-NETWK5) 00-DB1000POS(IN-NETWK5)CBR DB-1000 20% SMALL GRP DB-1000 POS SMALL GRP DB-1000 20% SG PRE-EX DB-1000 20% SG PRE-EX CBRA DB-1000 POS SMALL GROUP CB DB-1000 20% PLAN SMALL CBR RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SP 10/80% 06 SP 10/80% 06 CB 00-DB 1000 SMALL GROUP 00-DB 1000 POS SMALL GROUP 00-DB 1000 SG PRE-EX 00-DB 1000 SG PRE-EX CBRA 00-DB 1000 POS SMALL COBRA 00-DB 1000 SMALL GRP COBRA RESERVED PPO RESERVED PPO 597 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit KB4 KB5 KB6 KB7 KB8 KB9 KBA KBP KBY KC1 KC2 KC3 KC4 KC5 KC6 KC7 KC8 KCC KCH KD2 KD3 KD4 KD5 KD6 KD7 KD8 KD9 KDC KDZ KE2 KE3 KE4 KE5 KE6 KE7 KE8 KE9 KEC KEH KEL KEZ KF2 KF3 KF4 KF5 KF6 KF7 KF8 KF9 KFA Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO OK TO USE ENTERED IN ERROR 00-DB 1000 POS SG PRE-EX 00-DB 1000 POS SG PRE-EX C PREMIER $10/80% PREMIER $10/80% COBRA PREMIER $10/80% PREMIER $10/80% COBRA PREMIER $10/80% SG PREMIER $10/80% SG COBRA PREMIER $10/80% SG PREMIER $10/80% SG COBRA SV 5/100% KCS 06 SV 5/100% KCS 06 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO DB-1000 SHARE PLAN DB-1000 SHARE PLAN COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 00-DB-1000 EVERETT MUTUAL SAVING COBR EVERETT MUTUAL SAVINGS 00-DB-1000 COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO ALREADY USED 598 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit KFB KFC KFD KG2 KG3 KG4 KG5 KG6 KG7 KG8 KG9 KH8 KH9 KHA KHJ KJ2 KJ3 KJ4 KJ5 KJ6 KJ7 KJ8 KJ9 KK1 KK2 KK3 KK4 KK5 KK6 KK7 KK8 KKA KKJ KL2 KL3 KL4 KL5 KL6 KL7 KL8 KL9 KM2 KM3 KM4 KM5 KM6 KM7 KM8 KM9 KP1 Plan / Benefit Description ALREADY USED ALREADY USED ALREADY USED RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SV 5/100% KCSHERIFFS 06 SV 5/100% KCSHERIFFS 06 CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PREMIER $10/80% PREMIER $10/80% COBRA PREMIER $10/80% PREMIER $10/80% COBRA PREMIER $10/80% SG PREMIER $10/80% SG COBRA PREMIER $10/80% SG PREMIER $10/80% SG COBRA KING CNTY POLICE DU COV 06 KING CNTY POLICE DUAL 06CB RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO POS $10/90%/65% 599 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit KP2 KP3 KP4 KPA KPB KPC KPD KPP KPY KQ1 KQ2 KQ3 KQ4 KQA KQB KQC KQD KQP KQY KR2 KR3 KR4 KR5 KR6 KR7 KR8 KR9 KRF KRP KRY KS2 KS3 KS4 KS5 KS6 KS7 KS8 KS9 KT2 KT3 KT4 KT5 KT6 KT7 KT8 KT9 KU2 KU3 KU4 KU5 Plan / Benefit Description POS $10/90%/65% COBRA POS $10/90%/65% POS $10/90%/65% COBRA POS $10/90%/65% POS $10/90%/65% COBRA POS $10/90%/65% POS $10/90%/65% COBRA POS-DB-1000 POS-DB-1000 COBRA POS $10/80%/60& POS $10/80%/60% COBRA POS $10/80%/60% POS $10/80%/60% COBRA POS $10/80%/60% POS $10/80%/60% COBRA POS $10/80%/60% POS $10/80%/60% COBRA DB-1000 POS (IN-NETWK 5) DB-1000 POS (IN-NETWK5)CBR RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO ALREADY USED 00-DB 1000 POS(IN-NETWK5) 00-DB1000POS(IN-NETWK5)CBR RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 600 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit KU6 KU7 KU8 KU9 KV2 KV3 KV4 KV5 KV6 KV7 KV8 KV9 KW2 KW3 KW4 KW5 KW6 KW7 KW8 KW9 KX2 KX3 KX4 KX5 KX6 KX7 KX8 KX9 KXF KY2 KY3 KY4 KY5 KY6 KY7 KY8 KY9 L01 L02 L03 L04 L05 L06 L07 L08 L09 L1I L1K L1L L1V Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO ALREADY USED RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO LIFE COVERAGE PLAN LIFE COVERAGE PLAN LIFE PLAN - SMALL GROUP LIFE PLAN - SMALL GROUP LIFE PLAN - SG INTERNET LIFE PLAN - SG INTERNET LIFE PLAN - LARGE GROUP LIFE PLAN - LARGE GROUP LIFE PLAN - LARGE GROUP 94-FB-1200 80/20 POS PLAN INDIVIDUAL CONV./COMP. 80/20 POS PLAN (COBRA) 601 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit L2K L2V L3K L3V LAA LAB LBW LBZ LC3 LC4 LC5 LC6 LC7 LC8 LC9 LF1 LM1 LM2 LM3 LO6 LO7 LP1 LP2 LP3 LP4 LPA LPB LPC LPD LTD LTM LW5 LW6 LW7 LW8 M10 MAA MAB MAM MCB MH1 MH2 MH3 MH4 MH5 MH6 MHA MHB MHC MHE Plan / Benefit Description 80/20 POS PLAN 80/20 POS PLAN COBRA 90/20 POS PLAN 90/20 POS PLAN COBRA SV 10/250A 06 SV 10/250A 06 CB LASCO BATHWARE LASCO BATHWARE COBRA LIFE PLAN - SMALL GROUP LIFE PLAN - SMALL GROUP LIFE PLAN - SG INTERNET LIFE PLAN - SG INTERNET LIFE PLAN - LARGE GROUP LIFE PLAN - LARGE GROUP LIFE PLAN - LARGE GROUP LIFE COVERAGE PLAN $75,000 LIFETIME MAX $250,000 LIFETIME MAXIMUM $500,000 LIFETIME MAXIMUM ALREADY USED ALREADY USED POS $20/80%/60% POS $20/80%/60% COBRA POS $20/80%/60% POS $20/80%/60% COBRA POS $20/80%/60% POS $20/80%/60% COBRA POS $20/80%/60% POS $20/80%/60% COBRA RESERVED FOR PPO LIFE $2MILLION LIFETIME MAXIMUM SV 15-30/250A 06 SV 15-30/250A 06 CB SV 15-30/250A 06 SV 15-30/250A 06 CB $10 MAN GEN SV 10/100% 06 SV 10/100 STD 06 CB AMER MED RESPONSE MH MH/CD AGE BAND PKG PLAN MENTAL HEALTH RIDER 1 MENTAL HEALTH-RIDER 2 OPTION A-MNTL HLTH BENEFIT OPTION B-MNTL HLTH BENEFIT OPTION C-MNTL HLTH BENEFIT OPTION D-MNTL HLTH BENEFIT CORE MENTAL HEALTH-PCWA CORE MENTAL BHP CORE MENTAL HEALTH-PBHI MH IP/100%/$250/OP/45DAYS 602 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit MHF MHK MHN MHO MHP MJ1 MJ2 MJ5 MJ6 MJ7 MJ8 MK5 MPB MPS MRA MTK MTM MW5 MW6 MW7 MW8 N01 N02 N03 N04 N05 N06 N07 N08 N09 N0H N0Z N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N1H N1I N1N N1Z N20 N21 N22 N23 Plan / Benefit Description FEDS MH IP-100%/OP$20 OV 30/200D FEDS MH06 CUSTOM MENTAL HEALTH FEDS OP$45/IP$250 MH 2005 POS MENTAL HEALTH ALREADY USED ALREADY USED SV $15/70% SG SV $15/70% SG CB SV $15/70% SG SV $15/70% SG CB ALREADY USED PEBB MENTAL HEALTH PEBB MH PENDING GRP RET RITE AID MENTAL HEALTH 10/5V 1YR MSG THRPY SH07 10/5V 1YR MSG THRPY SH08 SV 20-40/400A 06 SV 20-40/400A 06 CB SV 20-40/400A 06 SV 20-40/400A 06 CB INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS NATL $20/$400 COBRA NATL PLAN $20/$400 COBRA INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS NATL $10/$100 COBRA ALREADY USED SV 5/100% NATL 06 CB NATL PLAN $10/$100 COBRA INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS 603 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit N24 N25 N26 N27 N28 N29 N2H N2I N2N N2Z N30 N3H N3I N3N N3Z N4H N4I N4N N4Z N5H N5I N5N N5Z N6H N6N N6Z N7H N7N N7Z N8H N8N N8Z N9H N9N N9Z NA1 NA2 NA3 NA4 NA5 NA6 NA8 NAA NAB NAC NAD NAE NAF NAG NAH Plan / Benefit Description INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS INDEMNITY PLANS NATL $15/$250 COBRA ALREADY USED SV 10/100% NAT'L 06 CB NATL PLAN $15/$250 COBRA INDEMNITY PLANS NATL $15/$400 COBRA ALREADY USED SV 15/100% NAT'L 06 CB NATL PLAN $15/$400 COBRA NATL $20/$250 COBRA ALREADY USED SV 10-20/100A NATL 06 CB NATL PLAN $20/$250 COBRA NATL $20/$400 COBRA ALREADY USED SV 15-30/250A NATL 06 CB NATL PLAN $20/$400 COBRA NATL $10/$100 COBRA SV 15-30/400A NAT'L 06 CB NATL PLAN $10/$100 COBRA NATL $15/$250 COBRA SV 20-40/250D NATL 06 CB NATL PLAN $15/$250 COBRA NATL $15/$400 COBRA SV 10/250A NAT'L 06 CB NATL PLAN $15/$400 COBRA NATL $20/$250 COBRA SV 15/250A NATL 06 CB NATL PLAN $20/$250 COBRA PHS NATL $5/100% CBRA PHS NATL $10/100% CBRA PHS NATL $10/$100/100%CBRA PHS NATL $10/$250/100%CBRA VHS NATL $15/$250/100%CBRA PHS NATL $15/100% CBRA PHS NAT'L $15/$100/100% CB PHS NATL $5/100% PHS NATL $10/100% PHS NATL $10/$100/100% PHS NATL $10/$250/100% PHS NATL $15/$250/100% PHS NATL $15/100% NATL POS $10/100%/70% NATL POS $10/90%/70% 604 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit NAI NAJ NAK NAL NAN NAO NAP NAQ NAR NB0 NB6 NB7 NB8 NB9 NBA NBB NBC NBD NBE NBF NBG NBH NBK NBL NBM NBN NBP NBQ NBR NC1 NC2 NC3 NC4 NC5 NC6 NC7 NCG NCH ND1 ND2 ND3 ND4 ND5 NDA NDB NDC NDD NDE NE1 NE2 Plan / Benefit Description PHS NAT'L $15/$100/100% NATL POS $10/$250/60% NATL POS $15/80%/60% NATL POS $15/$150/70% NATL POS $10/100%/70% NATL POS $10/90%/70% NATL POS $10/$250/60% NATL POS $15/80%/60% NATL POS $15/$150/70% SV $20-$40/$400D NATL CB SV $10-$20/$100A NATL CB SV $15-$30/$250A NATL CB SV $15-$30/$400A NATL CB SV $20-$40/$250D NATL CB SV $10-$20/$100A NATL SV $15-$30/$250A NATL SV $15-$30/$400A NATL SV $20-$40/$250D NATL SV $20-$40/$400D NATL SV 10-20/100A NATL 06 SV 10-20/100A NATL 06 CB SV 15-30/250A NATL 06 SV 15-30/250A NATL 06 CB SV 15-30/400A NAT'L 06 SV 15-30/400A NAT'L 06 CB SV 20-40/250D NATL 06 SV 20-40/250D NATL 06 CB SV 20-40/400D NATL 06 SV 20-40/400D NATL 06 CB NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 2B $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET SV 20-40/250A NATL 07 CB SV 20-40/250A NATL 07 NATL POS $10/100%/70% CBRA NATL POS $15/$150/70% CBRA NATL POS $10/90%/70% CBRA NATL POS $10/$250/60% CBRA NATL POS $15/80%/60% CBRA NATL POS $10/100%/70% NATL POS $15/$150/70% NATL POS $10/90%/70% NATL POS $10/$250/60% NATL POS $15/80%/60% NATL $5/100% COBRA NATL $10/100% COBRA 605 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit NE3 NE4 NE5 NE6 NE7 NE8 NEA NEB NEC NED NEE NEF NEG NEH NF4 NF5 NF6 NF7 NF8 NFD NFE NFF NFG NFH NGA NGB NGC NGD NGH NGZ NH0 NH1 NH2 NH3 NH4 NH5 NH6 NH7 NH8 NH9 NHZ NI1 NI2 NI3 NI4 NI5 NJ1 NJ2 NJ3 NJ4 Plan / Benefit Description NATL $15/100% COBRA NATL $10/$100/100% COBRA NATL $10/$250/100% COBRA NATL $15/$250/100% COBRA NATL $15/$100/100% COBRA NATL $35/$500D COBRA NATL $5/100% NATL $10/100% NATL $15/100% NATL $10/$100/100% NATL $10/$250/100% NATL $15/$250/100% NATL $15/$100/100% NATL $35/$500D SV $10-$20/$100A NATL CB SV $15-$30/$250A NATL CB SV $15-$30/$400A NATL CB SV $20-$40/$250D NATL CB SV $20-$40/$400D NATL CB SV $10-$20/$100A NATL SV $15-$30/$250A NATL SV $15-$30/$400A NATL SV $20-$40/$250D NATL SV $20-$40/$400D NATL NAT'L PLN 2C $20 GRP RET NAT'L PLN 2C $20 GRP RET NAT'L PLN 2D $20 GRP RET NAT'L PLN 2D $20 GRP RET SV 20-40/250A NATL 07 CB NATL POS $10/100%/70% CBRA NATL $20/$400 NATL $10/$100 NATL $15/$250 NATL $15/$400 NATL $20/$250 NATL $20/$400 NATL $10/$100 NATL $15/$250 NATL $15/$400 NATL $20/$250 NATL POS $10/90%/70% COBRA ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED SV $5/100% NATL CB SV $10/100% NATL CB SV $15/100% NATL CB SV $10/$100A NATL CB 606 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit NJ5 NJ6 NJ7 NJ8 NJ9 NJA NJB NJC NJD NJE NJF NJG NJH NJJ NJK NJL NJM NJN NJP NJQ NJR NJS NJT NJU NJV NJW NJX NJY NJZ NK1 NK2 NK3 NK4 NK5 NK6 NK7 NK8 NKA NKB NKC NKD NKE NKF NKG NKH NKZ NL1 NL2 NL3 NL4 Plan / Benefit Description SV $10/$250A NATL CB SV $15/$250A NATL CB SV $15/100A NATL CB SV $35/$500D NATL CB SV 35/500D NAT'L 06 CB SV $5/100% NATL SV $10/100% NATL SV $15/100% NATL SV $10/$100A NATL SV $10/$250A NATL SV $15/$250A NATL SV $15/100A NATL SV $35/$500D NATL SV 35/500D NAT'L 06 SV 5/100% NATL 06 SV 5/100% NATL 06 CB SV 10/100% NAT'L 06 SV 10/100% NAT'L 06 CB SV 15/100% NAT'L 06 SV 15/100% NAT'L 06 CB SV 10/100A NAT'L 06 SV 10/100A NAT'L 06 CB SV 10/250A NAT'L 06 SV 10/250A NAT'L 06 CB SV 15/250A NATL 06 SV 15/250A NATL 06 CB SV 15/100A NATL 06 SV 15/100A NATL 06 CB NATL POS $10/$250/60% CBRA NATL $5/100% COBRA NATL $10/100% COBRA NATL $15/100% COBRA NATL $10/$100/100% NATL $10/$250/100% COBRA NATL $15/$250/100% COBRA NATL $15/$100/100% COBRA NATL $35/$500D COBRA NATL $5/100% NATL $10/100% NATL $15/100% NATL $10/$100/100% NATL $10/$250/100% NATL $15/$250/100% NATL $15/$100/100% NATL $35/$500D NATL POS $15/80%/60% COBRA NATL POS $10/100%/70% CBRA NATL POS $15/$150/70% CBRA NATL POS $10/90%/70% CBRA NATL POS $10/$250/60% CBRA 607 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit NL5 NL8 NLA NLB NLC NLD NLE NLZ NM0 NM1 NM2 NM3 NM4 NM5 NM6 NM7 NM8 NM9 NMH NMI NMJ NMK NML NMM NMN NN1 NN2 NN3 NN4 NN5 NN6 NN7 NN8 NNA NNB NNC NND NNE NNF NNG NNH NNK NNL NNM NNN NNP NNQ NNR NNS NNT Plan / Benefit Description NATL POS $15/80%/60% CBRA 24HR NURSLINE WL-SH/GR08 NATL POS $10/100%/70% NATL POS $15/$150/70% NATL POS $10/90%/70% NATL POS $10/$250/60% NATL POS $15/80%/60% NATL POS $15/$150/70% CBRA NATL PLAN $20/$400 NATL PLAN $10/$100 NATL PLAN $15/$250 NATL PLAN $15/$400 NATL PLAN $20/$250 NATL PLAN $20/$400 NATL PLAN $10/$100 NATL PLAN $15/$250 NATL PLAN $15/$400 NATL PLAN $20/$250 MH IP/100%/OP/OV 45DAY/VIS MH IP/100%/OP$5OV 45DAYS MH IP/100%/OP$15OV 45 DAYS MH IP/100%/OP$20OV 45 DAYS MH IP/100%/OP$30OV 45 DAYS MH IP/100%/OP$40OV 45 DAYS MH IP-100%/OP-$35 45 DAYS SV $5/100% NATL CB SV $10/100% NATL CB SV $15/100% NATL CB SV $10/100A NATL CB SV $10/$250A NATL CB SV $15/$250A NATL CB SV $15/100A NATL CB SV $35/$500D NATL CB SV $5/100% NATL SV $10/100% NATL SV $15/100% NATL SV $10/$100A NATL SV $10/$250A NATL SV $15/$250A NATL SV $15/100A NATL SV $35/$500D NATL SV 10/250A NAT'L 06 SV 15/100A NATL 06 SV 10/100% NAT'L 06 SV 5/100% NATL 06 SV 15/250A NATL 06 SV 10-20/100A NATL 06 SV 10/100A NAT'L 06 SV 15-30/400A NAT'L 06 SV 20-40/250D NATL 06 608 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit NNU NNV NNW NNY NNZ NO4 NO5 NO6 NO7 NOZ NPM NPZ NQ0 NQ1 NQ2 NQ3 NQ4 NQ5 NQ6 NQ7 NQ9 NQA NQB NQC NQD NQE NQF NQG NQH NQJ NQK NQL NQM NQN NQP NQQ NQR NQS NQT NQU NQV NQW NQX NQY NQZ NRZ NS1 NS2 NS3 NS4 Plan / Benefit Description SV 15/100% NAT'L 06 SV 15-30/250A NATL 06 SV 35/500D NAT'L 06 SV 20-40/400D NATL 06 NATL POS $10/100%/70% CBRA ALREADY USED ALREADY USED ALREADY USED ALREADY USED NATL POS $10/90%/70% COBRA MH IP/100%/OP/OV 45DAY/VIS NATL POS $10/$250/60% CBRA ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED AVAIL USE IN SEATTLE ONLY ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY SV 10/100A NAT'L 06 CB AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY NATL POS $15/80%/60% COBRA NATL POS $15/$150/70% NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 3 $15 GRP RET NAT'L PLN 2A $10 GRP RET 609 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit NS5 NS6 NS7 NSA NSB NSC NSD NSE NSF NSG NSK NSN NSS NTF NTN NTS NU1 NU2 NU3 NU4 NU5 NUA NUB NUC NUD NUE NUF NUG NUH NUK NUL NUM NUN NUP NUQ NUR NWA NWB NWG NWI NWN NWZ NY1 NY2 NY3 NY4 NY5 NY6 NY8 NYA Plan / Benefit Description NAT'L PLN 2B $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED SV 25/80% NSHORE 06 SV 25/80% NSHORE 06 CB SV NSHORE $25/80%/$100D OK TO USE SV 15/100A NATL 06 AB 0/12-1W NON-ER TRANS SH08 ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY NON-WOVEN $0/100% NON-WOVEN $10/$200 SV 20-40/250A NATL 07 ALREADY USED SV 35/500D NAT'L 06 CB ALREADY USED PHS NATL $5/100% COBRA PHS NATL $10/100% COBRA PHS NATL $10/$100/100% CBR PHS NATL $10/$250/100% CBR PHS NATL $15/$250/100% CBR PHS NATL $15/100% COBRA PHS NAT'L $15/$100/100% CB PHS NATL $5/100% 610 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit NYB NYC NYD NYE NYF NYI NYN NZA NZB NZS O1C O1K O1Q O1R O1U O1V O1W O1X O2Q O2R O2U O2V O2W O2X O3Q O3R O3U O3V O3W O3X O4Q O4R O4U O4V O4W O4X O5Q O5R O5U O5V O5W O5X O6Q O6R O6U O6V O6W O6X O71 O72 Plan / Benefit Description PHS NATL $10/100% PHS NATL $10/$100/100% PHS NATL $10/$250/100% PHS NATL $15/$250/100% PHS NATL $15/100% PHS NAT'L $15/$100/100% SV 20-40/400D NATL 06 CB NON-WOVEN $0/100% COBRA NON-WOVEN $10/$200 COBRA SV NSHORE $25/80%/$100D CB NAT'L PLN 1 $5 GRP RET TEST 10-20/750A T2A GR07 15-25/200D T3A GR07 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 10-20/750A T2A GR07 15-25/200D T3A GR07 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 10-20/750A T2A GR07 15-25/200D T3A GR07 15-25/200D T3A GR07 10-20/750A T2A GR07 10-15/50A T1A GR07 10-15/50A T1A GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 15-25/130D T2B GR07 15-30/220D T3B GR07 15-30/220D T3B GR07 15-25/130D T2B GR07 5-20/100A T1B GR07 5-20/100A T1B GR07 ALREADY USED ALREADY USED 611 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit O7Q O7R O7U O7V O7W O7X O81 O82 O8Q O8R O8U O8V O8W O8X O91 O92 O9Q O9R O9U O9V O9W O9X OA1 OA2 OA4 OB1 OB2 OB4 OC1 OC2 OC4 OC6 OC7 OCC OEP OF1 OF2 OF3 OF4 OF5 OF6 OF7 OF8 OF9 OFA OFB OFC OFD OFE OFP Plan / Benefit Description 10-25/150D T2C GR07 20-35/250D T3C GR07 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 ALREADY USED ALREADY USED 10-25/150D T2C GR07 20-35/250D T3C GR07 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 ALREADY USED ALREADY USED 10-25/150D T2C GR07 20-35/250D T3C GR07 20-35/250D T3C GR07 10-25/150D T2C GR07 10-20/200A T1C GR07 10-20/200A T1C GR07 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET NAT'L PLN 2 $10 GRP RET 10/100% NON-AARP GR08 RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO RESERVED FOR RX PPO 10/100% NON-AARP GR08 612 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit OJ1 OJ2 OJ4 OK1 OK2 OKY OKZ OL1 OL2 OL4 OM1 OM2 OM4 ON2 ON4 OOA OOM OON OOZ OP1 OP2 OP4 OPM OQ2 OQ4 OQH ORH ORX OS1 OS2 OS4 OS6 OS7 OSS OT1 OT2 OT4 OU1 OU2 OU4 OV1 OV2 OV4 OVA OVB OVT OW1 OW2 OW4 OWA Plan / Benefit Description NAT'L PLN 1 $5 GR 06 NAT'L PLN 1 $5 GR 06 NAT'L PLN 2 $10 GR 06 NAT'L PLN 2 $10 GR 06 NAT'L PLN 2 $10 GR 06 15-25/500A AARP GR08 15-25/500A AARP GR08 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 OUT OF AREA PLAN 10-20/250A NON-AARP GR08 POS - OUT OF AREA OUT OF AREA PLAN (COBRA) NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GRP RET 10-20/250A NON-AARP GR08 NAT'L PLN 1 $5 GR 06 NAT'L PLN 1 $5 GR 06 5/100% NON-AARP GR08 5/100% NON-AARP GR08 OTHR RX NOT THRU RX SOL NAT'L PLN 1 $5 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 2A $10 GRP RET NAT'L PLN 3A $15 GRP RET NAT'L PLN 3B $15 GRP RET NAT'L PLN 2 $10 GRP RET NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2A $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 2B $10 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 NAT'L PLN 3A $15 GR 06 10/100% AARP GR08 15/250A NON-AARP GR08 ALREADY USED IN TX NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GR 06 NAT'L PLN 3B $15 GRP RET CLRK PEBB-GR 613 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit OWB OWL OWM OX1 OX2 OX4 OXA OXB OY1 OY2 OYD OYE OZ1 OZ2 OZ4 P1C P1K P1V P1Z P2C P2P P2Z P3C P3P P3Z P4P P5P P6H P6P P7E P7F P7P P8C P8K P8L P8P P8S P9P PA2 PA3 PA4 PA5 PA6 PA7 PA8 PA9 PAC PB1 PB2 PB3 Plan / Benefit Description SEATTLE PEBB-GR 10/150D PEBB NO-AARP GR08 10/150D PEBB NO-AARP GR08 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 NAT'L PLN 2C $20 GR 06 10/100% AARP GR08 15/250A NON-AARP GR08 NAT'L PLN 2 $10 GR 06 NAT'L PLN 2 $10 GR 06 5/100% AARP GR08 5/100% AARP GR08 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 NAT'L PLN 2D $20 GR 06 94-CF-500 90/5 POS PLAN 90/5 POS PLAN (COBRA) 94-CF-500 COBRA CF-500 PLAN (REVISED) RESERVED PPO CF500 COBRA (REVISED) CF-500 RESERVED PPO CF-500 COBRA RESERVED PPO RESERVED PPO 15-25/100A GR06 RESERVED PPO 15-30/200A PEBB GR07 15-30/200A PEBB GR07 RESERVE PPO POS $20/80%/60% 15-30/200A PB NON-AARP GR8 15-30/200A PB NON-AARP GR8 RESERVED PPO POS $20/80%/60% RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PPO ADMINISTRATIVE CHARGE 7G/$7BR/$14M BOEING RET. $0G/$0BR/$0M PEBB RET RX. $5G/$10BR/$25NF QW 614 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit PB4 PB5 PB6 PBA PBB PBC PBD PBE PBF PBG PBH PBI PBJ PBK PBL PBN PBR PBS PBU PC8 PCA PCB PCC PCE PCF PCG PCH PCI PCJ PCK PCL PCM PCZ PD6 PDC PEA PEC PED PEE PEF PEG PEH PEK PEV PEZ PF2 PF3 PF4 PF5 PF6 Plan / Benefit Description $10G/$20BR/$30NF $5G/$10BR/$25NF RE $5G/$5B TRI-MET PPO - PFFS PPO - PFFS $5G/$10BR/$25NF $10G/$20BR/50%NF $5G/$10BR/$1500MX RESERVED PFFS RESERVED PFFS SV 10/200D PEBB 2005 SV 10/200D PEBB 2005 CB SV 10/200D PEBB 2005 SV 10/200D PEBB 2005 CB SV 20/100% PANASONIC 06 SV 20/100% PANASONIC 06 CB $10G/$25B/$40NF SV 20/100% PANASONIC 06 SV 20/100% PANASONIC 06 CB POS $20/80%/60% PPO - PFFS PPO - PFFS CF-500 PPO - PFFS SV $15-$30/$100A PHS SV $15-$30/$100A PHS CB SV $15-$30/$100A PHS SV $15-$30/$100A PHS CB DO NOT USE SV 20-40/200A PHS 06 CB SV 20-40/200A PHS 06 SV 20-40/200A PHS 06 CB CF-500 COBRA PDV CUSTOM DENTAL & VISION DOMESTIC PARTNERS SV 15-20/100A PRUD 06 PEBB PLAN SV 15-20/100A PRUD 06 SV 15-20/100A PRUD 06 CB SV 15-20/100A PRUD 06 CB RESERVED PFFS RESERVED PFFS RESERVED PFFS AVAIL FOR USE SEATTLE ONLY PEBB PLAN COBRA RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 615 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit PF7 PF8 PF9 PFA PFB PFC PFD PFL PGD PGE PGF PGH PH2 PH3 PH4 PH5 PH6 PH7 PH8 PH9 PIA PIB PIC PID PIE PIF PIG PIH PII PIK PIL PIN PIO PJ5 PJ6 PJ7 PJ8 PJA PJB PJL PK5 PK6 PK7 PK8 PKA PKB PL1 PL2 PL3 PL4 Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO SP $15/100%-70% SP $15/100%-70% CB SP $15/100%-70% SP $15/100%-70% CB FEDERAL EMPLOYEES PPO -PFFS PPO - PFFS RESERVED PFFS RESERVED PFFS RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO SP $10/80%-60% SP $10/80%-60% CB SP $10/80%-60% SP $10/80%-60% CB RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS RESERVED RX PFFS SP 15/100% 06 SP 15/100% 06 CB SP 15/100% 06 SP 15/100% 06 CB SP $20/80%-60% SP $20/80%-60% CB AVAIL USE IN SEATTLE ONLY PACKAGE PLAN PACKAGE PLAN COBRA PACKAGE PLAN PACKAGE PLAN COBRA ALREADY USED ALREADY USED PREFERRED $15/$350 PREFERRED $15/$350 COBRA PREFERRED $15/$350 PREFERRED $15/$350 COBRA 616 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit PL5 PL6 PLC PLD PLL PLM PLP PLZ PMD PMK PNA PNB POA POB PP5 PP6 PPA PPB PPC PPD PPE PPF PPG PPH PPK PPL PPM PPP PPQ PPR PPS PPT PPU PPV PPW PPX PPY PPZ PQ5 PQ6 PQ7 PQ8 PR1 PR2 PS1 PS2 PS5 PS6 PS8 PSC Plan / Benefit Description SV 20/80% POLYCLINIC 05 SV 20/80% POLYCLINIC 06 POLYCLINIC POLYCLINIC SV 20/80% POLYCLINIC 05 CB SV 20/80% POLYCLINIC 06 CB PAYMENT LAG PREMIUM ALLOC POLYCLINIC COBRA PPO - PFFS RESERVED PFFS ALREADY USED ALREADY USED POS OUT OF AREA POS OUT OF AREA SP 20/80% 06 SP 20/80% 06 CB RESERVED PPO RESERVED PPO PEBB PLAN - 94 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO PEBB PLAN / POS /95 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVE PPO RESERVED PPO PEBB / POS / 95 / COBRA PEBB PLAN - 94 COBRA SP 10/80% 06 SP 10/80% 06 CB SP 10/80% 06 SP 10/80% 06 CB PREFERRED PLAN PREFERRED PLAN SV 30/500A PRINT SPEC SV 30/500A PRINT SPEC CB SV 30/500A PRINT SPC 05 SV 30/500A PRINT SPC 05 CB POS $20/80%/60% $5G/$15BR RETIREE 617 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit PSD PSG PSP PW2 PW5 PW8 PW9 PWA PWB PYI PZ1 PZ2 PZA PZB PZD Q1A Q1K Q1L Q1S Q1V Q1X Q1Z Q2A Q2Z Q5E Q5F Q7C QAC QAJ QAZ QBA QBZ QC1 QC2 QC3 QC4 QCC QCZ QD1 QD2 QD3 QD4 QE1 QE2 QE3 QE4 QE5 QE6 QE7 QE8 Plan / Benefit Description SV 30/500A PRINT SPC 06 SV 30/500A PRINT SPC 06 CB AVAIL USE IN SEATTLE ONLY SH-SEATTLE PEBB PEBB-WA SECURE HORIZONS PEBB SH SH-CLRK PEBB CLRK PEBB-GR SEATTLE PEBB-GR RESERVED PFFS PREFERRED PLAN (COBRA) PREFERRED PLAN (COBRA) POS OUT OF AREA COBRA POS OUT OF AREA COBRA POLYCLINIC COBRA 00-FB 2500 SMALL GROUP 90/20 POS PLAN 90/20 POS PLAN (COBRA) 00-FB 2500 SG PRE-EX 90/20 POS PLAN 00-FB 2500 SG PRE-EX CBRA 00-FB 2500 SMALL COBRA 00-FB 2500 00-FB 2500 COBRA ALREADY USED ALREADY USED ALREADY USED SV 10-20/100A 06 SV 10-20/100A 06 CB AVAIL USE IN SEALLTE ONLY 00-FB-2500 00-FB-2500 COBRA ADVANTAGE $20/$200 ADVANTAGE $20/$200 COBRA ADVANTAGE $20/$200 ADVANTAGE $20/$200 COBRA AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY SV 20/300D SV 20/300D CB SV 20/300D SV 20/300D CB SV $20/$500D SV $20/$500D CB SV $20/$500D SV $20/$500D CB SV $20/$500D SG SV $20/$500D SG CB SV $20/$500D SG SV $20/$500D SG CB 618 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit QF1 QF2 QF3 QF4 QH1 QH2 QH3 QH4 QI1 QI2 QI3 QI4 QJ1 QJ2 QJ3 QJ4 QK1 QK2 QK3 QK4 QK5 QK6 QK7 QK8 QW2 QW3 QW4 QWB QWC QWD R10 R15 R1C R1H R1K R1L R1V R1Z R2C R2H R2L R2S R2X R3C R3H R3L R3S R3X R3Z R4C Plan / Benefit Description SV 20/250A SV 20/250A CB SV 20/250A SV 20/250A CB PREFERRED $20/$250 PREFERRED $20/$250 COBRA PREFERRED $20/$250 PREFERRED $20/$250 ADVANTAGE $20/$200 ADVANTAGE $20/$200 COBRA ADVANTAGE $20/$200 ADVANTAGE $20/$200 COBRA ADVANTAGE $20/$300 ADVANTAGE $20/$300 COBRA ADVANTAGE $20/$300 ADVANTAGE $20/$300 COBRA ADVANTAGE $20/$500 ADVANTAGE $20/$500 COBRA ADVANTAGE $20/$500 ADVANTAGE $20/$500 COBRA ADVANTAGE $20/$500 SG ADVANTAGE $20/$500 COBRA ADVANTAGE $20/$500 SG ADVANTAGE $20/$500SG COBRA QWEST $10/$100 QWEST 15-30/150A QWEST 15-30/150A QWEST $10/$100 COBRA QWEST 15-30/150A COBRA QWEST 15-30/150A COBRA O/P PRESCR DRUGS $100 DED $15 OR 50% 94-DE-3000 PLAN US WEST CUSTOM COBRA 80/10 POS PLAN US WEST CUSTOM PLAN 80/10 POS PLAN COBRA 94-DE-3000 PLAN COBRA BASIC HLTH PLN NON SUB PACKAGE PLAN (COBRA) PACKAGE PLAN PACKAGE PLAN SG PRE-EX PACKAGE PLAN SG PRE-EX CBR DJ-000 BASIC HEALTH BENEFI E/10 PLAN COBRA E/10 PLAN DJ-000 BHP SG PRE-EX DJ-000 BHP SG PRE-EX CBRA DJ-000 BASIC HEALTH-COBRA $10/250 NAT'L ACCT PLAN 619 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit R4H R4L R4Z R50 R5H R5L R6C R6H R6L R6Z R7H R7L RA1 RA2 RA3 RA4 RB3 RB5 RB7 RB8 RBA RBB RBC RBZ RC5 RC6 RC7 RC8 REC REK REP REV REY REZ RFA RFC RFE RFF RFH RFZ RG0 RG1 RG2 RG3 RG4 RG6 RG7 RG8 RGC RGZ Plan / Benefit Description STANDARD $10/250 PLAN CBRA STANDARD $10/250 PLAN $10/250 NAT'L ACCT PLANCBR O/P PRESCR DRUGS $50 DED PLAN B 10/250 COBRA PLAN B 10/250 DE-3000 US WEST CUSTOM 1-00 COBRA US WEST CUSTOM PLAN 1-00 DE-3000 COBRA QWEST 2002 COBRA QWEST 2002 RITE AID - SEATTLE RITE AID-CLARK COUNTY SV 20/250A RITE AID 05 SV 20/250A RITE AID 05 $3/$8/$23 $5/$10/$25 $7/$12/$27 $8/$13/$28 $10/$15/$30 $15/$25/$40 PEBB PLAN 96 PEBB PLAN 96 PACKAGE PLAN 2002 PACKAGE PLAN 2002 COBRA PACKAGE PLAN 2002 PACKAGE PLAN 2002 COBRA PEBB HMO EFF 1-99 EVERGREEN (80/10 POS) PEBB-POS EVERGREEN 80/10 POS COBRA PEBB-POS COBRA PEBB COBRA EFF 1-99 SV 20/250A RITE AID 06 DE-3000 SV 20/250A RITE AID 06 CB SV 20/250A RITE AID 06 SV 20/250A RITE AID 06 CB DE-3000 COBRA $10G/$15B/$30NF RE $10G/$20B RETIREE $10G/$35B RETIREE $15G/$25B/$40NF $200 DED $15G/$25B/$40NF RE $5G/$15B RETIREE $5G/$25B RETIREE $7G/$12B/$27NF RET PEBB 2002 PEBB 2002 COBRA 620 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit RH8 RHH RHK RHV RJ1 RJ2 RK1 RK2 RK5 RK6 RKE RLG RM3 RM5 RM7 RM8 RMR RN1 RN2 RN3 RN4 RN5 RN6 RNG RNH RNJ RNK RNL RP1 RP5 RP8 RPA RPB RPC RPE RPH RPL RPP RPX RPY RPZ RSG RSH RSM RT3 RT5 RT7 RT8 RTA RTB Plan / Benefit Description $8 MAN GEN CUSTOM E 10 PLAN COBRA HARSCH INVESTMENTS POS HARSCH INVESTMENTS POS COB ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED ALREADY USED SV 20/90% RITE AID 07 SV 20/90% RITE AID 07 $3 MAN GEN $5 MAN GEN $7/$7+DIF $8 MAN GEN $15G/$20B/$30NF $7G/$14B GRP RET $10G/$20B GRP RET $10G/$25B GRP RET $10G/$20B/$40NF $10G/$20B/$50NF $15G/$25B/$40NF $7G/$14B $10G/$20B $10G/$25B $10G/$20B/$40NF $15G/$25B/$40NF $10G/$20B/$30NF $5G/$15B $8G/$13B ALREADY USED ALREADY USED THRIFTY PAYLESS PLAN RESPITE/PERS CARE SH07 CUSTOM PLAN E10 COBRA CUSTOM PLAN E10 PEBB-POS RESPITE/PERS CARE WL-SH08 PEBB-POS (COBRA) THRIFY PAYLESS PLAN COBRA SV 20/90% RITE AID 07 CB $6G/$9BR RETIREE $10G/$13BR RETIREE $3G/$8B $5G/$10B $7/$12/$7+DIF $8G/$13B $5G/$10B $10G/$20B 621 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit RTC RTD RTH RTL RTN RTS RTW RUC RUZ RW5 RW6 RW7 RW8 RWC RX0 RX1 RX2 RX3 RX4 RX5 RX8 RXP RZ1 RZ2 RZ3 RZ4 RZE S10 S1H S1K S1L S1P S1V S1Y S2K S2V S3K S3V S4K S4V S52 S70 S71 S72 S7Z S80 S81 S82 S8Z S90 Plan / Benefit Description $5G/$10B $0 $0 BHP+ CUSTOM E 10 PLAN $10G/50%B $5G/50%B COPAY VARIES US WEST CUSTOM PLAN US WEST CUSTOM CBRA PLAN SV 20/80% 06 SV 20/80% 06 CB SV 20/80% 06 SV 20/80% 06 CB BHP NON SUBSIDIZED $0 $1 $2 $3 $4 $5 $8 50% TO $50 RITE AID - SEATTLE COBRA RITE-AID CLK COUNTY COBRA SV 20/250A RITE AID 05 CB SV 20/250A RITE AID 05 CB SV 20/90% RITE AID 07 CB SHARE PLAN 10-20 $15/$250/100%EDS COBRA 100/15 PLAN POS $15/$250/100% EDS POS CLARK COUNTY 100/15 PLAN POS (COBRA) POS CLARK COUNTY COBRA 100/15 POS PLAN 100/15 POS PLAN COBRA POS PLAN 100/15 POS PLAN 100/15 COBRA POS $15/100%/70% POS $15/100%/70% COBRA STANDARD 5 PLAN VALUE $25/70% $25/70% $25/70% COBRA VALUE $25/70% COBRA VALUE $20/80% $20/80% $20/80% COBRA VALUE $20/80% COBRA VALUE $15/90% 622 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit S91 S92 S9Z SA2 SAC SAF SAH SAK SAV SAZ SB1 SB2 SB4 SBG SBK SBO SBV SC1 SC3 SC5 SC7 SCC SCO SCZ SE3 SE7 SEP SER SEZ SF1 SF2 SF3 SF4 SFC SFD SFE SFM SFP SFW SFX SFZ SG1 SGA SGC SGH SGL SGM SGZ SH1 SH2 Plan / Benefit Description $15/90% $15/90% COBRA VALUE $15/90% COBRA STANDARD 10 PLAN SV 25/90%/200A SSDST 06 SAFEWAY/VONS SV 25/90%/200A SSDST 06 CB 100/15 CUSTOM POS PLAN 100/15 CUSTOM POS COBRA SAFEWAY/VONS COBRA SH WESTERN WA PT B ONLY SH WALLA WALLA PT B ONLY SH EASTERN WA PT B ONLY SHWA BOEING RETIREES POS 15/100 WALLA WALLA CST SH BOEING NORTH AMERICAN POS 15/100 WALLA WALLA CBR GRP RET CLRK CTY $10 GRP RET CLRK CTY $3 GRP RET CLRK CTY $5 GRP RET CLRK CTY $7 GRP RET STD $10 CLK COUNTY SAFECO SAFECO COBRA SH PLUS 3 SH PLUS 7 COLUMBIAN HMO SUPP ELIGIBILITY RIDER COLUMBIAN HMO COBRA SAFEWAY/VONS $20/250A SAFEWAY/VONS $20/250A CBRA SAFEWAY/VONS $20/250A SAFEWAY/VONS $20/250A CBRA SPLIT FAMILY COVERAGE $10/$30/$60 SF SAFECO STATE FARM 20-30/250A COLUMBIAN HMO SAFEWAY/VONS STATE FARM 20-30/250A CBRA COLUMBIAN HMO COBRA SH WA GROUP RETIREE $10 SH WA RETIREE GROUP 5 SV 20/250A SFWAY 06 SV 20/250A SFWAY 06 CB SV 20/250A SFWAY 06 CB SV 20/250A SFWAY 06 SOUND PARTNERSHIP COBRA SH WESTERN WASHINGTON SH WALLA WALLA 623 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit SH3 SH4 SH5 SH6 SH7 SH8 SHA SHB SHP SHZ SK1 SK2 SKC SKL SLF SNS SNZ SO1 SO2 SO3 SO4 SOA SOB SOC SOD SP1 SPG SPH SPP SPY SR1 SRC SRH SRP SRY SRZ SS1 SS5 SSK SSP SSR SSY ST1 ST2 STD STF STX SU8 SU9 SUW Plan / Benefit Description SH COWLITZ COUNTY SH EASTERN WASHINGTON SH WESTERN WA PT B ALONE SH EASTERN WA PT B ALONE SH WALLA WALLA PT B ALONE SH COWLITZ PT B ALONE SH GRP RETIREE PLAN ($5) SH GRP RETIREE PLAN ($7) PEBB SH SOUND PARTNERSHIP COBRA ALREADY USED ALREADY USED SV 25/200A + 80% SSD 07 SV 25/200A + 80% SSD 07 CB RX SLF SOLUTIONS NORTHSHORE SCHL DIST NORTHSHORE SCHL DIST CB POS $15/100%/70% POS $15/100%/70% COBRA POS $15/100%/70% POS $15/100%/70% COBRA POS $15/100%/70% POS $15/100%/70% COBRA POS $15/100%/70% POS $15/100%/70% COBRA SUPPLEMENTAL LIFE BENE SOUND PARTNERSHIP SOUND PARTNERSHIP PEBB-POS $0 COPAY PEBB-POS $0 COPAY SEARS PLAN PEBB HMO $0 DUAL COVERAGE PEBB HMO $0 DUAL COBRA COLUMBIAN POS COLUMBIAN POS COBRA SEARS PLAN (COBRA) GRP RET SEATTLE $10 GRP RET SEATTLE $5 SILVER SNEAKERS SH06 COLUMBIAN POS SLV SNEAK/FITNESS BEN GR06 COLUMBIAN POS STANDARD PLAN STANDARD PLAN RESERVED FOR PPO LIFE STATE FARM 20-30/250A STATE FARM 20-30/250A CBRA SH GRP RETIREE US WEST SH GRP RETIREE US WEST SH GRP RETIREE US WEST 624 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit SW1 SW2 SW3 SW4 SW5 SW6 SW7 SW8 SWK SWP SWV SWY SWZ SXP SXY SZ0 SZ1 SZ2 SZE T10 T1H T1K T1L T1V T2C T2E T2F T3P T4P TAC TAE TAX TAZ TBC TBZ TC1 TC2 TC3 TC4 TJA TJB TK1 TK2 TK3 TK4 TM6 TM7 TMJ TNC TP3 Plan / Benefit Description SV 20/250A SAFEWAY SV 20/250A SAFEWAY CB SV 20/250A SAFEWAY SV 20/250A SAFEWAY CB SV 25/70% 06 SV 25/70% 06 CB SV 25/70% 06 SV 25/70% 06 CB WALLA WALLA POS-SW WA MED CTR EA-480 WALLA WALLA (COBRA) POS-SW WA MED CTR EA480 CB SAFEWAY/VONS COBRA SW WA MEDICAL CENTER POS SW WA MED CENTER POS COBRA SHARE PLAN 10-20 COBRA STANDARD PLAN (COBRA) STANDARD PLAN (COBRA) SAFECO COBRA $10G/$15B PLAN E/10 COBRA 90/10 POS PLAN PLAN E/10 90/10 POS PLAN (COBRA) BASIC HLT PLN SUBSIDIZED ALREADY USED ALREADY USED 15-20/100A GR06 5-10/100% GR06 PEBB 10/100 PLAN 1-99 SV 20-35/90% TENET 07 PCW PREMIUM TAX PEBB 10/100 CUSTOM1-99CBRA PEBB 2002 PEBB 2002 COBRA PREFERRED $10/$250 PREFERRED $10/$250 COBRA PREFERRED $10/$250 PREFERRED $10/$250 COBRA TMJ A TMJ B PREFERRED $10/$250 PREFERRED $10/$250 COBRA PREFERRED $10/$250 PREFERRED $10/$250 COBRA AVAIL USE IN SEATTLE ONLY AVAIL USE IN SEATTLE ONLY TMJ-CUSTOM BENEFIT RESERVED FOR THINC $10/20% TOWERS PERRIN $15 PLAN 625 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit TP4 TPA TPB TPE TPF TPH TPK TPL TPV TSA TSB TTH TTL TTT TW5 TW6 TW7 TW8 TWC U01 U02 U03 U04 U05 U06 U07 U08 U09 U10 U11 U12 U13 U14 U15 U16 U17 U18 U19 U1H U1L U20 U21 U22 U23 U24 U25 U26 U27 U28 U29 Plan / Benefit Description TOWERS PERRIN $15 PLAN AVAIL SEATTLE ONLY ALREADY USED ALREADY USED ALREADY USED 5-10/100% GR06 PEBB 15-20/100A GR06 PEBB (COBRA) ALREADY USED ALREADY USED THRIFTY PAYLESS THRIFTY PAYLESS TEST CODE/ DO NOT USE SV 15/90% 06 SV 15/90% 06 CB SV 15/90% 06 SV 15/90% 06 CB WASH BASIC HEALTH - SUBS USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO HEALTH ALLIANCE PLN(COBRA) HEALTH ALLIANCE PLAN USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO 626 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U42 U43 U44 U45 U46 U47 U48 U49 U50 U51 U52 U53 U54 U55 U56 U57 U58 U59 U60 UCW UCZ UFC UFS UHC UNA UND UNG UNJ UNL UNZ UTC V00 V01 V02 V03 V04 V05 V06 Plan / Benefit Description USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO USUAL & CUSTOMARY PPO SV 15-25/250A UNITED 06 SV 15-25/250A UNITED 06 CB SV 15-25/250A UNITED 06 SV 15-25/250A UNITED 06 CB DUAL-OPTION - UHC 06 SV 20-30/250A UL 06 SV 20-30/250A UL 06 SV 20-30/250A UL 06 CB SV 20-30/250A UL 06 CB UNDERWRITERS $15/100% UNDERWRITERS $15/100% CBR TAKING CHARGE OF YOU PEBB DUAL COVERAGE VISION VSP-CUSTOM VISION BENEFIT VSP STANDARD PLAN VSP VISION PLAN A/10 VISION SERVICE PLAN B/10 PEBB - VISION CARE EXAM PLUS ($5) 627 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit V07 V0E V0H V10 V12 V15 V1B V1C V1H V1K V1L V1V V1Z V25 V27 V2A V2B V2C V2F V2H V2K V2L V2S V2V V2Z V3A V3B V3C V3H V3K V3L V3V V3Z V4A V4B V4H V4K V4V V5A V5B V6A V6B V8P V8Q V8R V8S V8T V8U V8V V8W Plan / Benefit Description VISION CARE $7 (VSP) VSP EXAM PLUS HIGHLINE ASO VISION PEBB - VISION CARE VISION CARE $12 (VSP) VISION CARE $15 (VSP) DUMMY 94-EB-1500 PLAN F (COBRA) 80/15 POS PLAN PLAN F 80/15 POS PLAN (COBRA) 94-EB-1500 COBRA VISION - THRIFTY/PAYLESS SC 20 ELIGIBILITY ONLY $5 OPTION A EXAM/HARDWARE $5 OPTION B EXAM/HARDWARE EB-1500 20% PLAN 25/70A TOWERS GR-VN06 VSP F PLAN COBRA 80/15 POS PLAN F PLAN SH $10/$100 ALLOW - COLE 80/15 POS PLAN COBRA EB-1500 20% PLAN COBRA $10 OPTION A EXAM/HARDWARE $10 OPTION B EXAM/HARDWARE 00-EB-1500 PLAN F COBRA 90/15 POS PLAN PLAN F 90/15 POS PLAN COBRA 00-EB-1500 COBRA $15 OPTION A EXAM/HARDWARE $15 OPTION B EXAM/HARDWARE DUMMY POS 90/15 PLAN POS PLAN 90/15 COBRA $20 OPTION A EXAM/HARDWARE $20 OPTION B EXAM/HARDWARE $25 OPTION A EXAM/HARDWARE $25 OPTION B EXAM/HARDWARE 0 REFRAC 1/V YR VN-GR08 5 REFRAC 1/V YR VN-GR08 10 REFRAC 1/V YR VN-GR08 15 REFRAC 1/V YR VN-GR08 20 REFRAC 1/V YR VN-GR08 25 REFRAC 1/V YR VN-GR08 30 REFRAC 1/V YR VN-GR08 35 REFRAC 1/V YR VN-GR08 628 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit V8X V9C V9S V9X V9Z VA1 VA2 VAA VAB VAC VAD VAE VAF VAG VAH VAI VAJ VAK VAL VAM VAN VB6 VBC VBJ VBK VBL VBM VBS VBX VBZ VC1 VC2 VC3 VC4 VCC VCZ VDA VDC VDZ VE1 VE2 VE3 VE7 VE8 VE9 VEF VEO VER VEZ VF1 Plan / Benefit Description 40 REFRAC 1/V YR VN-GR08 EB-1500 20% PLAN SMALL GRP EB-1500 20% SG PRE-EX EB-1500 20% SG PRE-EX CBRA EB-1500 20% PLAN SM GRPCBR $5 PEBB VISION-SH PENDING VALUE PLAN VSP OPTION A VSP OPTION B VSP - CORE VISION CARE $15 1-99 VSP - CORE - CLARK COUNTY VSP - CORE $5 EXAM VSP - CORE $15 EXAM VSP - CORE $20 EXAM VSP - CORE $25 EXAM $5 OPTION A EXAM/HRDWARE $15 OPTION A EXAM/HRDWARE $20 OPTION A EXAM/HRDWARE $25 OPTION A EXAM/HRDWARE VSP $35 EXAM ONLY 25/150A 2 YRS SH-VN06 00-EB 1500 SMALL GROUP $5 OPTION B EXAM/HRDWARE $15 OPTION B EXAM/HRDWARE $20 OPTION B EXAM/HRDWARE $25 OPTION B EXAM/HRDWARE 00-EB 1500 SG PRE-EX 00-EB 1500 SG PRE-EX CBRA 00-EB 1500 SMALL GRP COBRA PREMIER $15/80% PREMIER $15/80% COBRA PREMIER $15/80% PREMIER $15/80% COBRA 00-EB-1500 00-EB-1500 COBRA 15/70A GR-VN07 EB-1500 20% PLAN EB-1500 20% PLAN COBRA SV $15/100% VERIZON SV $15/100% VERIZON CB SECURE HORIZONS PLUS SECURE HORIZONS PLUS 7 SV $15/100% VERIZON SV $15/100% VERIZON CB SV 20/100A VERIZON 07 35 EXAM ONLY VSP VERIZON $10/100 VERIZON $10/100 COBRA SECURE HORIZONS B ONLY 629 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit VF5 VF6 VF7 VF8 VF9 VFA VFD VFF VFP VFQ VG1 VG3 VG5 VG6 VG7 VGP VGQ VH1 VH6 VHF VHN VI1 VI2 VI3 VI4 VI5 VI6 VI7 VI8 VJ1 VJ3 VJ5 VJ7 VJB VJQ VK1 VK2 VK3 VK4 VKC VKF VKP VL6 VMB VMQ VN1 VN2 VN5 VNQ VNW Plan / Benefit Description SECURE HORIZONS B ONLY SECURE HORIZONS B ONLY SECURE HORIZONS B ONLY SH CLARK COUNTY B ONLY SH CLARK COUNTY B ONLY 30 EXAM FEDS VN06-PDV PDV $40 EXAM ONLY FED 2005 SV 20/100A VERIZON 07 0/75A 2YRS VN-GR08 0/125A 2YRS VN-GR08 SECURE HORIZONS PLUS 10 SECURE HORIZONS PLUS 3 SECURE HORIZONS PLUS 5 25/75A VN-GR06 SECURE HORIZONS PLUS 7 5/75A 2YRS VN-GR08 5/125A 2YRS VN-GR08 CUSTOM VISION-EXAM ONLY 10/70A 2 YRS VN06 VSP SV 20/100A VERIZON 07 CB HONEYWELL VSN $15 EXAM ADVANTAGE $15/$200 ADVANTAGE $15/$200 COBRA ADVANTAGE $15/$200 ADVANTAGE $15/$200 COBRA ADVANTAGE $15/$200 SG ADVANTAGE $15/$200 SG COBR ADVANTAGE $15/$200 SG ADVANTAGE $15/$200 SG COBR SECURE HORIZONS RET GRP 10 SECURE HORIZONS RET GRP 3 SECURE HORIZONS RET GRP 5 SECURE HORIZONS RET GRP 7 SV 20/100A VERIZON 08 10/75A 2YRS VN-GR08 PREMIER $15/80% PREMIER $15/80% COBRA PREMIER $15/80% PREMIER $15/80% COBRA VISION KING CNTY SHERIFFS SV 20/100A VERIZON 07 CB 10/125A 2YRS VN-GR08 ADV WELLNESS LITE SH-WL06 SV 20/100A VERIZON 08 CB 15/125A 2YRS VN-GR08 GRP RET $5OV/$125 ALLOWNCE GRP RET $10OV/$75 ALLOWNCE GRP RET $20V/$75 ALLOWANCE 20/75A 2YRS VN-GR08 NON-WOVEN $0 EXAM/HARDWARE 630 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit VO1 VO2 VO3 VO4 VOA VOB VOC VOD VP1 VP2 VP3 VP4 VP5 VP7 VPA VPB VPE VPP VPS VPV VPZ VQC VQD VQH VQP VQR VR3 VR5 VR7 VS1 VS5 VS6 VS7 VS8 VS9 VSA VSB VSC VSN VSQ VST VSX VVB VVP VVQ VWB VWP VX1 VX3 VX5 Plan / Benefit Description POS $15/90%/65% POS $15/90%/65 COBRA POS $15/90%/65% POS $15/90%/65% COBRA POS $15/90%/65% POS $15/90%/65% COBRA POS $15/90%/65% POS $15/90%/65% COBRA PEBB SH PNDING EFF1-00 WA1 PEBB SH PNDING VSN EFF1-00 SECURE HORIZONS PLUS 3 HONEYWELL VSN $10 EXAM SECURE HORIZONS PLUS 5 SECURE HORIZONS PLUS 7 VISION PREMIUM ALLOCATION PEBB VISION (VSP) RESERVED PFFS 20/125A 2YRS VN-GR08 $30 PRINT SPEC VSP 10/150A 2YRS PEBB GR-VN07 25/150A 1YR PEBB GR-VN07 15/130A 1YR DLX VN-SH08 30/70A 2YRS VN-GR08 30/70A 2YRS VN-SH08 25/70A 2YRS VN-GR08 0/70A 2YRS VN-SH08 SECURE HORIZONS PLUS 3 SECURE HORIZONS PLUS 5 SECURE HORIZONS PLUS 7 SECURE HORIZONS STANDARD SECURE HORIZONS STANDARD SECURE HORIZONS STANDARD SECURE HORIZONS STANDARD SH CLARK COUNTY SH CLARK COUNTY VSP OPTION A - CLARK CNTY VSP OPTION B - CLARK CNTY VISTA OPTICAL SUMMARY CORE VISTA OPTICAL 30/70A 2YRS SH-VN07 VISTA CUSTOM PLAN 15/130A 1YR DLX SH-VN07 SV 20/100A VERIZON 08 15/75A 2YRS VN-GR08 25/75A 2YRS VN-GR08 SV 20/100A VERIZON 08 CB 25/125A 2YRS VN-GR08 SECURE HORIZONS RET GRP 10 SECURE HORIZONS RET GRP 3 SECURE HORIZONS RET GRP 5 631 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit VX7 VYP VZ2 VZC W1C W1H W1K W1L W1V W1Z W2H W2L W3H W3L W4C W4Z W5C WA1 WA2 WA3 WA4 WA5 WA6 WAB WAC WAJ WAL WAP WAZ WBA WBC WBJ WBL WBN WBU WBW WBY WC1 WC2 WC3 WC5 WC6 WC7 WC8 WCA WCB WCC WCD WCE WCH Plan / Benefit Description SECURE HORIZONS RET GRP 7 10/150A 2YRS PEBB VN-GR08 VALUE PLAN (COBRA) 25/150A 2YRS PEBB VN-GR08 94-EE-3000 PLAN PLAN E/15 COBRA 90/15 POS PLAN PLAN E/15 90/15 POS PLAN (COBRA) 94-EE-3000 PLAN COBRA E/15 PLAN COBRA E/15 PLAN PLAN E/15 COBRA PLAN E/15 EE-3000 EE-3000 COBRA ALREADY USED SH KING COUNTY SH KING COUNTY PT B ONLY SH LEW/PIER/SNO/THUR SH LEW/PIER/SNO/THUR PT B SH COWLITZ/WALLA SH COWLITZ/WALLA PT B ONLY SV 10/100% 06 10-20/100D COWLITZ SH05 SV 10/100% 06 CB WALGREENS $25/$40/$250A WEIGHT ALTERATION PROGRAMS WALGREENS $25/$40/$250A CB SV 20/80% SG 08 SV 20/80% WELLS FRGO 06 SV 20/80% WELLS FRGO 06 CB SV 25-40/250A WALGRN 05 SV 25-40/250A WALGRN 05 CB ARP MCC ES CWTZ PP SH08 ARP MCC ES CWTZ SH08 ARP MCC ES CWTZ EP SH08 SH CLARK COUNTY SH CLARK COUNTY PRT B ONLY CLARK SH STD PLAN PREMIER $15/70% SG PREMIER $15/70% SG COBRA PREMIER $15/70% SG PREMIER $15/70% SG COBRA CLARK - SH STD PLAN SOUTHERN SH $10/$20/$100 WA SH SOUTHERN STD PLAN WA SH SOUTHERN STD PLAN 05 10-20 COWLITZ C SH06 EPO ALREADY USED 632 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit WCL WCN WCP WD1 WD2 WD3 WD4 WDA WDB WDC WDZ WE1 WE2 WE3 WE4 WE5 WE6 WE7 WE8 WEA WF1 WF2 WF3 WF4 WF5 WF6 WF7 WF8 WFB WFC WFD WFE WFF WFG WFJ WFS WFX WFZ WG5 WG6 WG7 WG8 WGA WGN WGR WH5 WH6 WH7 WH8 WHB Plan / Benefit Description ALREADY USED 10-20 COWLITZ C SH06 10-20 COWLITZ C SH06 ODP SV 15/90% SV 15/90% CB SV 15/90% SV 15/90% CB SV 20/80% SG 08 AB NO GOOD DO NOT USE EE-3000 EE-3000 COBRA SV $20/80% SV $20/80% CB SV $20/80% SV $20/80% CB SV $20/80% SG SV $20/80% SG CB SV $20/80% SG SV $20/80% SG CB SV 25/70% SG 08 SV $25/70% SV $25/70% CB SV $25/70% SV $25/70% CB SV $25/70% SG SV $25/70% SG CB SV $25/70% SG SV $25/70% SG CB WELLS FARGO BANK WELLS FARGO BANK SV $20/80% WELLS FARGO SV $20/80% WELLS FARGO CB SV $20/80% WELLS FARGO SV $20/80% WELLS FARGO CB SV 20/80% WELLS FRGO 06 WELLS FARGO BANK SV 20/80% WELLS FRGO 06 CB WELLS FARGO BANK COBRA SV 20/80 SG06 SV 20/80 SG06 CB SV 20/80 SG06 SV 20/80 SG06 CB SV 25/70% SG 08 CB SV 25-40/250A WALGRN 05 CB SV 25-40/250A WALGRN 05 SV 25/70% SG06 SV 25/70% SG06 CB SV 25/70% SG06 SV 25/70% SG06 CB SV 20/80% SG 08 633 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit WIT WJ1 WJ2 WJA WJB WK1 WK2 WK5 WK6 WK7 WK8 WKA WKB WKC WKD WL6 WLA WLC WLE WLF WLG WLS WLZ WMA WME WMN WMP WNA WNU WNW WNY WP1 WPR WPS WPT WQB WQR WQS WQT WRR WRS WRT WS0 WS1 WS2 WS3 WS4 WS5 WS6 WS7 Plan / Benefit Description WA INFERTILITY TREATMENT ALREADY USED ALREADY USED SV 25-40/250A WLGRN 08 SV 20/80% SG 08 CB ALREADY USED ALREADY USED PREMIER $15/70% SG PREMIER $15/70% SG COBRA PREMIER $15/70% SG PREMIER $15/70% SG COBRA SV 25-40/250A WLGRN 08 CB SV 25/70% SG 08 SV 10/100% 06 SV 10/100% 06 CB AVAIL USE IN SEATTLE ONLY SV 25-40/250A WLGRN 06 SV 25-40/250A WLGRN 06 CB SV 25-40/250A WLGRN 06 SV 25-40/250A WLGRN 06 CB WALGREENS $25/$40/$250A WELLS FARGO BANK WELLS FARGO BANK COBRA SV 25-40/250A WLGRN 08 10-20 COWLITZ M SH06 EPO 10-20 COWLITZ M SH06 10-20 COWLITZ M SH06 ODP SV 25-40/250A WLGRN 08 CB ARP MCC ES CLRK PP SH08 ARP MCC ES NO SH08 ARP MCC ES CLRK EP SH08 SECURE HORIZON LKWD PLAN 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 SV 25/70% SG 08 CB 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 WA-SH STD PLAN PART B SH KING COUNTY SH KING COUNTY PRT B SH PIERCE/SNOHOMISH SH PIERCE/SNOHOMISH PRT B SH COWLITZ SH COWLITZ PART B SH LEWIS/THURSTON 634 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit WS8 WS9 WSA WSB WSC WSD WSE WSF WSG WSH WSI WSJ WSK WSL WSM WSN WSV WT6 WT7 WT9 WTE WTN WTP WU6 WU7 WU9 WUE WUN WUP WUR WUS WUT WV1 WV2 WVR WVS WVT WXR WXS WXT WZC WZG WZS X10 X15 X1A XA1 XA2 XA3 XA4 Plan / Benefit Description SH LEWIS/THURSTON PRT B WA-SH STD PLAN WA - SH STD PLAN WA - SH STD PLAN PART B WA - SH STD PLAN LAKEWOOD NORTHERN SH $15/$30/$200 CENTRAL SH $15/$30/$200 LAKEWOOD SH $20/$30/$200 SH INDIVIDUAL PART B WA SH NORTHERN STD PLAN WA SH CENTRAL STD PLAN WA SH CENTRAL STD PLAN 05 STEVENS MEDIUM (ASO) WA SH VALUE PLAN 05 WA SH NORTHERN STD PLAN 05 WA SH STD PLAN PART B 05 STEVENS MEDIUM (ASO) COBRA MCC COWLITZ PP-PL SH07 MCC COWLITZ EP-PL SH07 MCC COWLITZ PLUS SH07 MCC COWLITZ EP SH07 MC COMP COWLITZ SH07 MCC COWLITZ PP SH07 MCC ESS COWLITZ PP-PL SH07 MCC ESS COWLITZ EP-PL SH07 MCC ESS COWLITZ PLUS SH07 MCC ESS COWLITZ EP SH07 MC COMP ESS COWLITZ SH07 MCC ESS COWLITZ PP SH07 15-25/200D T3A GR07 15-30/220D T3B GR07 20-35/250D T3C GR07 SH CLARK COUNTY SH CLARK COUNTY PT B ONLY 10-20/750A T2A GR07 15-25/130D T2B GR07 10-25/150D T2C GR07 10-15/50A T1A GR07 5-20/100A T1B GR07 10-20/200A T1C GR07 WELLS FARGO BANK COBRA WALGREENS $25/$40/$250A CB WELLS FARGO BANK COBRA $10 $15 $10 $10 $8 $10G/50%B $10 635 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit XA5 XA7 XA8 XA9 XAA XAB XAD XAF XAG XAH XAI XAJ XAK XAL XAM XAN XAO XAP XAQ XAR XAS XAT XAU XAV XAW XAX XAY XAZ XB1 XB2 XB3 XB4 XB5 XB6 XB7 XB8 XBB XBC XBD XBE XBF XBG XBH XBI XBJ XBK XBL XBM XBN XBO Plan / Benefit Description $10G/$20B $10 20% $10G/$10BR CUSTOM $5 $10G/50%B $8 $10 $7G/$7B $10 $5 $5 $8 $6G/$12B $8 $12 $12 $15 $15 $5G/$10B $5G/$10B $8 $5G/$12B $5G/$15B $5 DUMMY $3 $5 50% 50% $10G/50%B $0 $0 $0 50% 20% $0 $5G/$15B 50% $0 RX VARIES $5 $3 $5 $5G/$15B $5 $5/$10/$25 $5 RX VARIES PACKAGE RX CO-PAY VARIES 636 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit XBP XBQ XBS XBU XBV XBW XBX XBY XCE XCN XCP XDE XED XEE XEN XEP XLD XLE XLN XLP XM1 XM5 XM7 XM8 XND XNE XNN XNP XS1 XS2 XS7 XXX Y1H Y1K Y1L Y1V Y2H Y2L Y3H Y3L Y4H Y4L YA3 YA5 YA8 YAA YAB YB5 YBA YBB Plan / Benefit Description $0G/$5B $10G/$20B RX VARIES ARP MCC 1 NO PP SH08 $5G/$15B ARP MCC 1 NO SH08 ARP MCC 1 NO DLX SH08 ARP MCC 1 NO EP SH08 15-30 NORTH C SH06 EPO 15-30 NORTH C SH06 15-30 NORTH C SH06 ODP $10 MCC 1 NO DELUXE SH07 MCC 1 NO EP SH07 MC COMP 1 NO SH07 MCC 1 NO PP SH07 MCC 3 NO DELUXE SH07 MCC 3 NO EP SH07 MC COMP 3 NO SH07 MCC 3 NO PP SH07 $10/10+DIF $5/$5+DIF $7/$7+DIF $8/$8+DIF MCC ESS NO DELUXE SH07 MCC ESS NO EP SH07 MC COMP ESS NO SH07 MCC ESS NO PP SH07 DISCOUNT ONLY PLAN $10 $7 NO BENEFIT PREFERRED $5 (COBRA) 90/5 POS PLAN PREFERRED $5 90/5 POS PLAN COBRA PLAN C (COBRA) PLAN C C PLAN COBRA C PLAN PLAN C COBRA PLAN C $3/$8/$23 $5/$10/$25 $8/$13/$28 $10/$15/$30 CSTM RX $10/$20/$30 $5/$10/$25 $10/$15/$30 $15G/$25B/$40NF 637 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit Z1L Z2P Z2T Z2U Z2X Z8P Z8X ZA2 ZA3 ZA4 ZA5 ZA6 ZA7 ZA8 ZA9 ZAU ZAW ZAX ZAY ZB2 ZB3 ZB4 ZB5 ZB6 ZB7 ZB8 ZB9 ZBD ZBE ZBN ZBP ZC2 ZC3 ZC4 ZC5 ZC6 ZC7 ZC8 ZC9 ZCE ZCN ZCP ZD2 ZD3 ZD4 ZD5 ZD6 ZD7 ZD8 ZD9 Plan / Benefit Description INDIVIDUAL CONV. MAJOR 10-15/50A T1A NON-AARP GR8 15-25/200D T3A NO-AARP GR8 15-25/200D T3A NO-AARP GR8 10-15/50A T1A NON-AARP GR8 10-20/200A T1C NO-AARP GR8 10-20/200A T1C NO-AARP GR8 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO ARP MCC 1 SO PP SH08 ARP MCC 1 SO SH08 ARP MCC 1 SO DLX SH08 ARP MCC 1 SO EP SH08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO MCC 1 SO DELUXE SH07 MCC 1 SO EP SH07 MC COMP 1 SO SH07 MCC 1 SO PP SH07 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 10-20 SOUTH C SH06 EPO 10-20 SOUTH C SH06 10-20 SOUTH C SH06 ODP RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO 638 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit ZE2 ZE3 ZE4 ZE5 ZE6 ZE7 ZE8 ZE9 ZF2 ZF3 ZF4 ZF5 ZF6 ZF7 ZF8 ZF9 ZG2 ZG3 ZG4 ZG5 ZG7 ZG8 ZG9 ZH2 ZH3 ZH4 ZH5 ZH6 ZH7 ZH8 ZH9 ZHD ZHE ZHI ZHN ZHP ZHQ ZHU ZHV ZHW ZHY ZJ2 ZJ3 ZJ4 ZJ5 ZJ6 ZJ7 ZJ8 ZJ9 ZJD Plan / Benefit Description RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO MCC 3 SO DELUXE SH07 MCC 3 SO EP SH07 ARP MCC 2 KING EP-PL SH08 MC COMP 3 SO SH07 MCC 3 SO PP SH07 ARP MCC 2 KING PP-PL SH08 ARP MCC 2 KING PP SH08 ARP MCC 2 KING PLUS SH08 ARP MCC 2 KING SH08 ARP MCC 2 KING EP SH08 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO MCC ESS SO DELUXE SH07 639 of 640 Plan Benefit - WA State WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA WA Plan / Benefit ZJE ZJN ZJP ZK2 ZK3 ZK4 ZK5 ZK6 ZK7 ZK8 ZK9 ZM2 ZM3 ZM4 ZM5 ZM6 ZM7 ZM8 ZM9 ZN2 ZN3 ZN4 ZN5 ZN6 ZN7 ZN8 ZN9 ZP2 ZP3 ZP4 ZP5 ZP6 ZP7 ZP8 ZP9 ZR2 ZR3 ZR4 ZR5 ZR6 ZR7 ZR8 ZR9 ZSK ZSV ZZZ Plan / Benefit Description MCC ESS SO EP SH07 MC COMP ESS SO SH07 MCC ESS SO PP SH07 RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO RESERVED PPO STEVENS LOW (ASO) STEVENS LOW (ASO) COBRA HISTORICAL PLAN 640 of 640
