Plan Benefit In Network Monthly premium Physician office visits copay Specialty physician office visit copay Inpatient hospital admission daily copay for days 1-5 Out-of-pocket maximum Prescription drug benefit

Medi-Pak Advantage (PFFS) Medi-Pak Advantage MA-PD (PFFS) Option 1 Medi-Pak Advantage MA-PD (PFFS) Option 2 Label Label Label Label Label Label Label Label Label Label Label Label Label Label Label Label Label Label

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H4213_Advantage_REV Website Submission (12/03/09)