Page 17 - 2017 US Benefits Guide - for all Capgemni employees in the FS SBU

Medical Plan Comparison Chart (continued) What’s a deductible?

Covered Premier PPO Basic PPO See Terms You Should
Know on page 11.
Health Services In-Network Out-of-Network 1 In-Network Out-of-Network 1
Vision Benefits (Once every 12 months)

Eye Exam Up to $50 reimbursement Up to $50 reimbursement
Frames Up to $40 reimbursement Up to $40 reimbursement
Lenses Up to $40 reimbursement Up to $40 reimbursement
Contacts (in lieu of glasses) Up to $50 reimbursement once Up to $50 reimbursement
Mental Health/Substance Abuse
Inpatient 85% after deductible 50% after deductible 2 75% after deductible 50% after deductible 2
Outpatient $20 oice visit co-pay 50% after deductible 2 $20 oice visit co-pay 50% after deductible 2
Substance Abuse 3 Unlimited Lifetime Maximum Unlimited Lifetime Maximum

Prescription Drug Retail Co-insurance
Generic 10% 50% 10% 50%
($5 min., $12 max.) after $12 co-pay ($5 min., $12 max.) after $12 co-pay
Preferred Brand 20% 50% 20% 50%
($20 min., $50 max.) after $50 co-pay ($20 min., $50 max.) after $50 co-pay
Non-Preferred Brand 40% 50% 40% 50%
($40 min., $100 max.) after $100 co-pay ($40 min., $100 max.) after $100 co-pay

Prescription Drug Mail Order Co-insurance (3-month supply)
Generic 10% 10%
($12 min., $30 max.) ($12 min., $30 max.)
Preferred Brand 20% N/A 20% N/A
($50 min., $125 max.) ($50 min., $125 max.)
Non-Preferred Brand 40% 40%
($100 min., $250 max.) ($100 min., $250 max.)

1 Out-of-network beneits will be based on maximum reimbursable costs as determined by BCBS of Illinois.
2 There is a 20% penalty for failure to pre-certify an out-of-network hospital coninement.
3 Certain limitations apply to the Lifetime Maximum Beneit. Please see the Summary Plan Description for details.

CAPGEMINI 2017 BENEFITS GUIDE 14