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IITML ~ Int~mentaJ Empøyee Ben8flts Pool SCHEDULE OF MEDICAL EXPENSE BENEFITS - FYO4-05 EARLY RETIREE BENEFITS PLANINON ENTITLED MEDICARE RETIREES Plan Benefits Effective: Precertification (800) 847-1213 Claims (800) 282-5385 This schedule represents a summary of benefits. For complete details of benefits and requirements please refer to the Medical Benefits Booklet. Eligibility - You are eligible if you are a retired employee under age 65 and not entitled to Medicare A & B. The early retiree must be an early retiree from a political subdivision of Texas and is performing the normal duties of a person of like age and gender, residing in the U.S. and not in fu1t-time military service. Are my dependents eligible? - Yes, if you are enro1ted in the plan, your spouse (not lega1ty separated or divorced) and/or child(ren), including stepchildren and adopted children, who are unmanied, dependent on you for support and under age 19 (25 if a fu1t-time student) are eligible. Dependents must be actively performing the normal duties of persons who are the same age and gender. Newborns are covered ftom birth provided we are notified of the birth and the appropriate premium is paid within 31 days of birth. Otherwise, the newborn is considered a late enro1tee and may not be enro1ted and may not be enro1ted until the next open enro1tment period. Disclaimer: Retiree Continuum of Care Benefits are not comprehensive major medical insurance. It is, however, a valuable benefit plan for Texas Political subdivisions wanting to provide an alternative lower cost coverage for early retirees. PPO - Passive Requested Provider Network care can be accessed. Calendar Year Maximums for High Plan Doctor's Office Visits (One visit may be used for wellness care) Diagnostic Testing and X-ray (One visit may be used for wellness care) Emergency Room Inpatient Surgery Outpatient Surgery Calendar Year Maximums for Standard Plan Doctor's Office Visits (No wellness visit included) Diagnostic Testing and X-ray (No wellness visit included) Emergency Room Inpatient Surgery Outpatient Surgery Physician Office Visit Fees (per visit) For treatment of injury or sickness per covered person per calendar year Chiropractic visits are included in these visits. Diagnostic Testing or X-ray (per visit) Medically necessary diagnostic tests and x-rays performed in a doctor's office or outpatient facility; one visit may be used for wellness care. Emergency Room (per visit) Applicable for emergency room visits when patient is not confined to the hospital. One visit each for injury or sickness per calendar year. Surgery Inpatient (per procedure) Outpatient - limited to one (1) inpatient and one (1) outpatient surgery (peñonned in a hospital or outpatient surgery center) per calendar year. C:\Documcnts and Setûngs\pndcrson\Loca1 SeUings\TCIJ1)OnIIy Intcmct FiJcs\OLKS\EarlyRct.doc 5 visits 3 visits 3 visit for injury/1 visit for sickness 1 surgery 1 surgery 4 visits 2 visits 3 visit for injury/1 visit for sickness 1 surgery 1 surgery BENEFIT PAYABLE High Standard $65 $30 $65 $30 $300 $75 $2,000 $800 $500 $200