DCCCA - Schedule of Benefits

SCHEDULE OF BENEFITS

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Plan Sponsor: DCCCA, Inc.

Benefit Period: January 1 - December 31

Covered Services	PPO	Non-PPO
Lifetime Benefit Maximum	$2,000,000 Deductible and Out-of-Pocket are combined for PPO and Non-PPO
Deductible(per Calendar Year) Deductible for PPO and Non-PPO are shared. Individual Major Medical Base Plan Comprehensive Buy Up Plan Family Major Medical Base Plan Comprehensive Buy Up Plan Other special deductibles may apply to specific services	$2,500 $1,000 $5,000 $2,000	$2,500 $1,000 $5,000 $2,000
Out-of-Pocket Maximum (per Calendar Year includes deductible) Out-of-Pocket for PPO and Non-PPO are shared. Individual Major Medical Base Plan Comprehensive Buy Up Plan Family Major Medical Base Plan Comprehensive Buy Up Plan Inpatient and Outpatient Surgery Penalty for failure to Precertify - $250 reduction in benefits	$3,500 $2,000 $7,000 $4,000	$3,500 $2,000 $7,000 $4,000
Standard Benefit Percentage	80%	60%
Standard Benefit Percentage for Care w/in Network where no Network Provider : 80%
Benefit Percentage for In-Network care by Non-Network Provider: PPO rate
Benefit Percentage for Emergent Non-Network Care While Traveling: PPO rate

Covered Services	PPO	Non-PPO
	Deductible and Coinsurance Apply Except as Provided:
Physician Services Major Medical Base Plan Comprehensive Buy Up Plan Office Visits Including office surgery, allergy testing and sterilization (vasectomy) Services rendered at time of visit	$30 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied $20 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied	60% of covered charges Calendar Year Deductible is applied 60% of covered charges Calendar Year Deductible is applied
Diagnostic Outpatient Lab and X-Ray Including CT scans and MRI scans per Calendar Year	100% of covered charges up to first $500. Calendar Year Deductible is not applied to first $500. After that, 80% of covered charges and the Calendar Year Deductible is applied	100% of covered charges up to first $500. Calendar Year Deductible is not applied to first $500. After that, 60% of covered charges and the Calendar Year Deductible is applied
Diagnostic Inpatient Lab and X-Ray	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Preventative Care[1] Major Medical Base Plan Comprehensive Buy Up Plan Pap Smear Mammograms Employees and eligible dependents age 35 or older PSA Tests Male employees and eligible dependents age 50 and older Routine Physical Examinations Employee, Spouse and each covered Dependent Child including x-rays and laboratory blood test after age 6	$30 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied $20 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied $300 Aggregate Preventative Care Max. per Calendar Year	60% of covered charges Calendar Year Deductible is applied 60% of covered charges Calendar Year Deductible is applied
Well Child/Well Baby Care Major Medical Base Plan Comprehensive Buy Up Plan Through age 6 including routine physical exams, hearing exams, vision exams, laboratory blood test and x-rays.	$30 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied $20 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied $300 Max. per Calendar Year	60% of covered charges Calendar Year Deductible is applied 60% of covered charges Calendar Year Deductible is applied
Immunizations Through age 6	100% of covered charges. Calendar Year Deductible and Wellness Benefit is not applied	100% of covered charges. Calendar Year Deductible and Wellness Benefit is not applied
Birthing Center	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Maternity Benefits	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Hospital Care (other than mental/nervous or substance abuse) Room and Board/Routine Services Physician Expenses	80% of covered charges Calendar Year Deductible is applied 80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied 60% of covered charges Calendar Year Deductible is applied
Outpatient Surgery	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Emergency Room[2] Emergency Illness Non-Emergency Illness	80%of covered charges Calendar Year Deductible is applied 80%of covered charges Calendar Year Deductible is applied	80%of covered charges Calendar Year Deductible is applied 60%of covered charges Calendar Year Deductible is applied
Urgent Care Facility	$50 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied $50 copay then 80% after co-pay amount if Facility does not bill as an "office visit". The calendar year deductible is applied	60% of covered charges Calendar Year Deductible is applied 60% of covered charges Calendar Year Deductible is applied
Private Duty Nursing $15,000 Max. per lifetime	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Ambulance	80% of covered charges Calendar Year Deductible is applied	80% of covered charges Calendar Year Deductible is applied
Organ Transplant	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Prosthesis	80% of covered charges deemed to be medically necessary. Calendar Year Deductible is applied	80% of covered charges deemed to be medically necessary. Calendar Year Deductible is applied
Skilled Nursing Facility 60 Days Max. per Calendar Year	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Home Health Care 40 Max. visits per Calendar Year	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Hospice Care $10,000 Max. per lifetime	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Physical Therapy 15 Days Max. per Calendar Year Major Medical Base Plan Comprehensive Buy Up Plan	$30 co-pay per visit, then 100% of covered charges up to the Calendar Year Max. The Calendar Year Deductible is not applied when only paying co-payment. After Calendar Year Max, 80% of covered charges and Calendar Year Deductible is applied $20 co-pay per visit, then 100% of covered charges up to the Calendar Year Max. The Calendar Year Deductible is not applied when only paying co-payment. After Calendar Year Max, 80% of covered charges and Calendar Year Deductible is applied	60% of covered charges The Calendar Year Deductible is applied. After the Calendar Year Max, 60% of covered charges and Calendar Year Deductible is applied 60% of covered charges The Calendar Year Deductible is applied. After the Calendar Year Max, 60% of covered charges and Calendar Year Deductible is applied
Occupational and Speech Therapy	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Chiropractic Care Major Medical Base Plan Comprehensive Buy Up Plan $1,500 Max. per Calendar Year	$30 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied $20 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied	60% of covered charges Calendar Year Deductible is applied 60% of covered charges Calendar Year Deductible is applied
Mental and Nervous/Substance Abuse Inpatient 15 Days Max. per Calendar Year Outpatient 45 Visits Max. per Calendar Year Major Medical Base Plan Comprehensive Buy Up Plan	80% of covered charges Calendar Year Deductible is applied $30 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied $20 co-pay per visit, then 100% of covered charges Calendar Year Deductible is not applied	60% of covered charges The Calendar Year Deductible is applied 50% of covered charges The Calendar Year Deductible is applied
Pre-Admission Testing (w/in 5 days of admission)	100% when required for a given procedure including testing for pre-certified outpatient surgery. Calendar Year Deductible is not applied	60% of covered pre-admission tests Calendar Year Deductible is applied
Second Surgical Opinion	100% of covered charges when required by the Plan. Calendar Year Deductible is not applied	60% of covered charges when required by the Plan. Calendar Year Deductible is applied
Durable Medical Equipment	80% of covered charges deemed to be medically necessary. Calendar Year Deductible is applied	60% of covered charges deemed to be medically necessary. Calendar Year Deductible is applied
Medical Supplies	80% of covered charges deemed to be medically necessary. Calendar Year Deductible is applied	60% of covered charges deemed to be medically necessary. Calendar Year Deductible is applied
Cardiac Rehabilitation Therapy	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Allergy Injections	$10 injection co-pay Calendar Year Deductible is not applied	60% of covered charges Calendar Year Deductible is applied
Wigs (Maximum benefit of $250 every 5 years)	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied
Biofeedback Therapy	80% of covered charges Calendar Year Deductible is applied	Not Covered
Temporomandibular Joint Disorder (TMJ) $2,000 Max. per lifetime	80% of covered charges Calendar Year Deductible is applied	60% of covered charges Calendar Year Deductible is applied

*Prescription Drug Co-pays*
*Pharmacy Option* *30 Day or Less Supply*	Generic Drug	Single Source Drug	Multi-Source Drug
Major Medical Base Plan	$25 Co-pay	$50 Co-pay	$75 Co-pay
Comprehensive Buy Up Plan	$20 Co-pay	$40 Co-pay	$60 Co-pay

*Mail Order Option* *90 Day Supply*	Generic Drug	Single Source Drug	Multi-Source Drug
Major Medical Base Plan	$37.50 Co-pay	$75 Co-pay	$112.50 Co-pay
Comprehensive Buy Up Plan	$30 Co-pay	$60 Co-pay	$90 Co-pay

1 If more than one of the services is billed in conjunction with an office visit, these services are considered as part of the office visit and are not subject to an additional co-payment.

2 If you receive Emergency care at a non-PPO Hospital for conditions that are emergent, payment will be considered at the PPO level for Covered Expenses received in the emergency room. If you are then admitted to the non-PPO Hospital, Covered Expenses for Hospital and Physician services will be considered at the PPO level for up to two days where your condition remains life threatening. After the second day in the non-PPO Hospital, Covered Expenses will be considered at the non-PPO level.