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EXHIBIT G <br /> HEALTH INSURANCE PLAN HIGHLIGHTS <br /> COVERAGE FOR ALL PLANS IN NETWORK OUT OF NETWORK <br /> Hospital benefit—Inpatient/Outpatient 80% of eligible charge 60%of eligible charge <br /> Medical/surgical Care(Physicians) 80% of scheduled maximum 60%of scheduled maximum <br /> allowance allowance <br /> Emergency Care 100%of eligible charge—no deductible <br /> Inpatient Mental 80%after deductible 60%after deductible <br /> Outpatient Mental 80%after deductible 60%after deductible <br /> Preventive Care: <br /> Evidence-based items/services rated 100% 60%after deductible <br /> A or B as recommended by U.S. deductible does not apply <br /> Preventive Services Task Force <br /> 80%after deductible 60%after deductible <br /> Chiropractic services $1000/calendar yr max $1000/calendar yr max. <br /> Prescription Medicines $10 Generic, $20 Formulary, $50 Non-Formulary <br /> Private duty nursing 80%after deductible <br /> 44 visits per calendar year <br /> Physical therapy 80% after deductible 60%after deductible <br /> 10 visit limit per calendar year 10 visit limit per calendar year <br /> Occupational therapy 80%after deductible 60% after deductible <br /> 10 visit limit per calendar year 10 visit limit per calendar year <br /> 80%after deductible 60%after deductible <br /> Speech therapy 10 visit limit per calendar year 10 visit limit per calendar year <br /> Waiting period of preexisting 365 days(Waived for employees providing a Certificate of <br /> conditions Creditable Coverage) <br /> $500 reduction in benefits for failure to notify National Health <br /> Precertification Service when receiving inpatient services <br /> MAJOR PLAN ELEMENTS Tier 1 Tier 2 Tier 3 <br /> Deductible(individual) In Network $250 $ 500 $ 750 <br /> (individual)Out of Network <br /> Family—3 individual deductibles $500 $1,000 $1,500 <br /> Out-of-Pocket Limit <br /> (individual) In Network $1,500 $2,000 $2,500 <br /> (individual) Out of Network $5,000 $6,000 $7,500 <br /> Family—3 individual limit <br /> Wellness Benefit/individual $250 $250 $250 <br /> Per year <br /> Health Credits/individual <br /> max of 4/individual $25 each $50 each $75 each <br /> NOTE: The above chart represents only a summary of plan benefits and related information, and is provided for <br /> illustrative purposes only. It is not intended as a substitute for the plan document. For detailed information on plan <br /> benefits,conditions, limitations,and exclusions,please refer to the plan document. <br /> 40 <br />