2010 General Exclusions and Limitations

HMO Two-Tier

0H15T0YY: Copay $15/$30

0H15WD1C: Copay $15/$30, $250/$500D

0H20T0YY: Copay $20/$40

0H20WD2C: Copay $20/$40, $250/$500D

0H25T1YY: Copay $25/$50

0H25WD5C: Copay $25/$50, $500/$1,000D

0H35WD5C: Copay $35/$70, $500/$1,000D

Meriter Choice Reward Plans

0H15MD5C: Copay $15/$30

0H20MD5C: Copay $20/$40

0H25MD5C: Copay $25/$50

0H35MD5C: Copay $35/$70

Meriter Choice Plan Amendment

POS Three-Tier

0P15G20A: $15/$30/20%

0P20G20A: $20/$40/20%

0P20F303: $20/$40/30%, $250/$500D

0P25G204: $25/$50/20%

0P25F314: $25/$50/30%, $500/$1,000D

0P35F304: $35/$70/30%, $500/$1,000D