Coventry HealthAmerica Small Business Solutions PENNSYLVANIA

Transcription

1 Coventry HealthAmerica Small Business Solutions PENNSYLVANIA Plan Name Coinsurance Single 2x Family PCP Office Visit Specialist Office Visit Convenience Care Urgent Care Emergency Room Labs X-ray Diagnostics PCP/SCP Labs X-ray Diagnostics Outpatient Inpatient Hospital Outpatient Facility Out-of-Pocket Max Single 2x Family Single 2x Family Out-of-Network Coinsurance Out-of-Pocket Max Single 2x Family Tier Pharmacy 1A/ Effective 1/1/14 Out-of-Pocket Pharmacy Maximum Platinum Premier PPO $20/$40 0% $0 $20 $40 $40 $40 $150 0% 0% $0 $0 $1,500 $5,000 40% $10,000 $3/$10 $35 $60 Platinum Premier PPO 500* 0% $500 $15 $30 $30 $30 $150 Ded Ded Ded / $0 Ded / $0 $1,500 $5,000 40% $10,000 $3/$10 $35 $60 Gold Premier PPO $25/$75 0% $0 $25 $75 $25 $75 $300 Included in Office Visit $25 $ 500 per Admit $75 $6,350 $5,000 30% $10,000 $3/$10 $40 $70 Gold Premier PPO % $1,000 $25 $50 $50 $75 $200 Ded Ded Ded Ded / $150 $3,000 $5,000 40% $10,000 $3/$10 $35 $60 Gold Premier PPO 1500* 0% $1,500 $15 $50 $50 $75 $300 Ded Ded Ded / $250 Ded / $150 $6,000 $5,000 40% $10,000 $3/$10 $40 $70 Gold Classic PPO % $1,000 $30 $60 $60 $60 $250 Ded / 10% Ded / 10% Ded / 10% Ded / 10% $5,500 $5,000 40% $10,000 $3/$10 $35 $60 Silver Premier PPO $25/$75* 0% $0 $25 $75 $25 $75 $500 Included in Office Visit $75 $2000 per Admit $75 $6,350 $5,000 30% $10,000 $3/$10 $40 $70 Silver Value PPO % $2,000 $30 $75 $75 $75 $300 Ded / 20% Ded / 20% Ded / 20% Ded / 20% $6,350 $5,000 40% $10,000 $3/$10 $40 $75 Silver Value PPO % $3,000 $20 $50 $20 $75 $300 20% Ded / 20% Ded / 20% Ded / 20% $6,350 $5,000 40% $10,000 $3/$15 $40 $75 Silver Value II PPO % $3,000 $30 $75 $75 $75 $300 Ded / 30% Ded / 30% Ded / 30% Ded / 30% $6,350 $5,000 40% $10,000 $3/$10 $40 $75 $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill $150 min. or 20% up to $300/fill 40% $4,850 40% Integrated Med/Rx 40% Integrated Med/Rx 40% $3,350 40% Integrated Med/Rx 40% Integrated Med/Rx 40% Integrated Med/Rx 40% Integrated Med/Rx 40% Integrated Med/Rx 40% Integrated Med/Rx Silver FlexChoice QHDHP Premier PPO 1500** 0% $1,500 Ded / $25 Ded / $50 Ded / $50 Ded / $50 Ded / $200 Ded Ded Ded Ded $3,000 $5,000 40% $10,000 Ded / $3/$10 Ded / $35 Ded / $60 Ded/$150 min. or 20% up to $300/fill Ded / 40% Integrated Med/Rx Silver FlexChoice QHDHP Premier PPO % $2,500 Ded / $20 Ded / $40 Ded / $40 Ded / $40 Ded / 150 Ded Ded Ded Ded $6,350 $5,000 40% $10,000 Ded / $3/$10 Ded / $35 Ded / $60 Ded / $150 min. or 20% up to $300/fill Ded / 40% Integrated Med/Rx Bronze FlexChoice QHDHP Premier PPO 5000* 0% $5,000 Ded / $20 Ded / $40 Ded / $40 Ded / $40 Ded / $150 Ded Ded Ded Ded $6,350 $5,000 40% $10,000 Ded / $3/$10 Ded / $35 Ded / $60 Ded / $150 min. or 20% up to $300/fill Ded / 40% Integrated Med/Rx Bronze FlexChoice QHDHP Premier PPO % $6,300 Ded Ded Ded Ded Ded Ded Ded Ded $6,300 $7,100 40% Unlimited Ded Ded Ded Ded Ded Integrated Med/Rx Bronze FlexChoice QHDHP Value PPO 2500** 20% $2,500 Ded / $25 Ded / $50 Ded / $75 Ded / $75 Ded / $300 Ded / 20% Ded / 20% Ded / 20% Ded / 20% $6,350 $5,000 40% $10,000 Ded / $3/$10 Ded / $45 Ded / $75 Ded / 20% Ded / 40% Integrated Med/Rx Bronze FlexChoice QHDHP Value PPO % $5,000 Ded / $20 Ded /$50 Ded / $20 Ded / $75 Ded / $250 Ded Ded Ded / 20% Ded / 20% $6,350 $10,000 40% $20,000 Ded / $3/$10 Ded / $35 Ded /$60 Ded/$150 min. or 20% up to $300/fill Ded / 40% Integrated Med/Rx NOTE REGARDING ALL PLANS Beginning in 2014, the Affordable Care t (ACA) requires all fully insured plans for small groups (2-50 employees) to offer at least bronze equivalent coverage. All benefit plans described here are available in BenefitExpress. Pediatric vision and dental are embedded in the plan designs listed above. at the participating provider level may not apply to qualified preventive services; see your Schedule of Benefits to determine if deductibles are waived for qualified preventive services. Lifetime maximum is unlimited. This grid is provided for demonstration purposes only. Actual benefits, cost sharing provisions, limitations and exclusions are set forth in the Certificate of Insurance issued to members. Pennsylvania in-area PPO products are underwritten by HealthAssurance Pennsylvania, Inc. All outof-area PPO products are underwritten by Coventry Health and Life Insurance company (d.b.a. HealthAmerica). This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have any questions call us at in Central Pennsylvania and in Western Pennsylvania. This brochure is not a contract. It is intended solely to provide you with an overview of the plan and you should not rely on it when trying to determine whether a service, etc. is covered under your health benefit plan. Complete details of benefits, terms and exclusions are set forth in the group contract. Platinum Gold Silver Bronze METALLIC VALUES/DESIGNATIONS 90% actuarial value 80% actuarial value 70% actuarial value 60% actuarial value **These qualified high deductible health plans have an umbrella deductible; the individual deductible applies when the Subscriber has an employee only policy. For policies that include the Subscriber and one or more dependents, the family deductible must be met before any family member begins to receive the benefits listed below, including prescription drug benefits covered under the prescription drug rider (except preventive services) *Out-Of-Area plan designs are available. Tier 1A Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Note: Mandatory generics required for all prescription drug plans. Mail Order N/A N/A Through the convenience of mail order, customers can receive their prescription drugs that fall under any tier at a 90-day supply. Includes common antibiotics, pain relievers, acid reducers, antidepressants, blood pressure and cholesterol lowering drugs, and more. Includes more generic and a few selected OTC (over-thecounter) drugs. Formulary brandname drugs. Nonformulary brand-name, and a few nonformulary generic drugs. These drugs may have a lower cost alternative on Tier 1 or Tier 2. Speciatly Drugs are limited to a one month supply HealthAmerica, HealthAssurance and the torch design are registered trademarks.

2 Preferred Provider Organization Underwritten by HealthAssurance Pennsylvania, Inc. This Schedule of Benefits, Covered Services, and Exclusions is part of your Individual Member Contract but does not replace it. Many words are defined elsewhere in the Contract, and other limitations or exclusions may be listed in other sections of your Contract. Reading this Schedule by itself could give you an inaccurate impression of the terms of your coverage. This Schedule must be read with the rest of your Contract. Prior authorization may be required for specific services. PPO Plan Benefits BENEFIT CATEGORIES AND COST SHARING Platinum Premier PPO $20/$40 PPO Member pays Participating Providers Non-Participating Providers Annual () Individual: $0 Individual: $5,000 Family: $0 Family: $10,000 Coinsurance (Coinsurance) 0% 40% Out-of-Pocket Maximum Individual: $1,500 Individual: $10,000 Family: $3,000 Family: $20,000 AMBULATORY SERVICES Office Visit Primary Care Physician $20 Copay /Coinsurance Specialist $40 Copay /Coinsurance Chiropractic Care $40 Copay /Coinsurance Limited to 20 visits per benefit year Surgery Primary Care Physician s Office 0% /Coinsurance Specialist s Office 0% /Coinsurance Free-Standing Facility 0% /Coinsurance Outpatient 0% /Coinsurance Outpatient Facility and Physician 0% /Coinsurance Services Hospice 0% /Coinsurance Home Health Care 0% /Coinsurance Limited to 60 visits per benefit year Skilled Nursing Facility 0% /Coinsurance Limited to 120 days per benefit year EMERGENCY CARE Convenience Care* $40 Copay /Coinsurance Urgent Care $40 Copay $40 Copay Emergency Room Care $150 Copay $150 Copay

3 Emergency Advanced Imaging / High Tech Radiology Emergency Transportation/ Ambulance Copay waived if admitted 0% 0% 0% 0% HOSPITALIZATION Inpatient Services 0% /Coinsurance Inpatient Physician and Surgical 0% /Coinsurance Services MATERNITY AND NEWBORN CARE Prenatal Office Visits 0% /Coinsurance Physician Charges, Prenatal, 0% /Coinsurance Postnatal, Ultrasound, Delivery Outpatient Ultrasound 0% /Coinsurance All Inpatient Services/Facility Charges 0% /Coinsurance MENTAL HEALTH/SUBSTANCE ABUSE DISORDER SERVICES INCLUDING BEHAVIORAL HEALTH MANAGEMENT Office $40 Copay /Coinsurance Outpatient and Partial 0% /Coinsurance Hospitalization Inpatient 0% /Coinsurance REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES Outpatient Rehabilitation Services 0% /Coinsurance PT/OT limited to 30 combined visits per benefit year ST limited to 30 visits per benefit year Habilitation Services 0% /Coinsurance Limited to 30 visits per benefit year Durable Medical Equipment 0% /Coinsurance Limited to once every 2 years for irreparable damage and/or normal wear LAB SERVICES Lab/Radiology Primary Care Physician s Office 0% /Coinsurance Specialist s Office 0% /Coinsurance Outpatient 0% /Coinsurance Diagnostic Mammogram Primary Care Physician s Office 0% /Coinsurance Specialist s Office 0% /Coinsurance Free-Standing Facility 0% /Coinsurance Outpatient 0% /Coinsurance Advanced Imaging / High Tech Radiology Primary Care Physician s Office 0% /Coinsurance Specialist s Office 0% /Coinsurance

4 Free-Standing Facility 0% /Coinsurance Outpatient 0% /Coinsurance PREVENTION/WELLNESS Preventive Care/Screening/ $0 /Coinsurance Immunization Preventive/Screening Limited to once per benefit year Mammogram Primary Care Physician s Office $0 /Coinsurance Specialist s Office $0 /Coinsurance Free-Standing Facility $0 /Coinsurance Outpatient $0 /Coinsurance PEDIATRIC SERVICES INCLUDING ORAL AND VISION CARE Pediatric Dental Care Type Coverage In & Out Preventive & Diagnostic Exams I 100% Cleanings I 100% X-rays I 100% Fluoride I 100% Sealants I 100% Basic Space Maintainers II 50% Fillings II 50% Adjustments to Dentures II 50% Anesthesia II 50% General Services II 50% Major Crowns III 50% Inlays III 50% Onlays III 50% Dentures III 50% Bridges III 50% Endo III 50% Perio III 50% Oral Surgery III 50% Implants III 50% Orthodontia IV 50% OOP Max Pediatric Vision Care Vision Screening for Children Eye Glasses for Children PRESCRIPTION DRUGS & OOP Max combined with medical, deductible does not apply to preventive & diagnostic services One routine eye examination per year One pair of standard eyeglass lenses or contact lenses per year; one frame every year Pharmacy Tier 1A: Lower Cost Preferred Generic Drugs No Rx deductible $4,850 Rx OOP Max Retail $3 / Mail Order $9

5 Tier 1: Preferred Generic Drugs Retail $10 / Mail Order $20 Tier 2: Preferred Brand Drugs Retail $35 / Mail Order $87.50 Tier 3: Non-Preferred Retail $60 / Mail Order $180 Brand/Generic Drugs Tier 4: Preferred Specialty Drugs Preferred Pharmacy $150 minimum or 20% with a max of $300 Tier 5: Non-Preferred Specialty Preferred Pharmacy 40% Coinsurance Drugs Vision Services Vision One Eyecare Program: Receive immediate savings on all eyecare needs--discounts on frames, lenses, disposable contacts, and even LASIK surgery--at participating providers through the EyeMed Vision Care network. PRECERTIFICATION REQUIREMENT When using a nonparticipating provider, the member must obtain precertification of nonemergency hospital and other facility (e.g., skilled nursing facilities, rehabilitation facilities, drug and alcohol treatment facilities) admissions, outpatient surgery and certain other services as stated in the Group Contract. If these services or admissions are not precertified and the service is not medically necessary, the member may be responsible for 100% of the cost of the services. LIFETIME MAXIMUM Unlimited This is not a contract. It is intended solely to provide you with an overview of the plan. Complete details of benefits, terms and exclusions are governed by your Group Contract. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have questions call us at in Central/Eastern Pennsylvania, and in Western Pennsylvania and Ohio. Benefits are administered on a contract year basis. Coinsurance is based on Eligible Charges as defined in your Certificate of Insurance. For non-participating providers, Eligible Charges are based on the lesser of the provider's billed charges or our Out-of-Network Rate, which is defined in your Certificate of Insurance. In addition to your copay or coinsurance, you are responsible for paying nonparticipating providers the difference between our out-of-network rate and their actual charge for nonemergency services. Your outof-pocket costs for nonemergency care from nonparticipating providers may be substantial. This document neither affirmatively nor negatively amends, extends, or alters the terms of or the coverage afforded by policy referenced herein *Convenience Care A condition that requires Convenience Care is an unexpected illness or injury that does not constitute an Emergency Medical Condition, but requires medical attention when you cannot see your family doctor right away. Convenience Care Centers are also useful for flu shots, vaccinations, and other shots

6 Preferred Provider Organization Underwritten by HealthAssurance Pennsylvania, Inc. This Schedule of Benefits, Covered Services, and Exclusions is part of your Individual Member Contract but does not replace it. Many words are defined elsewhere in the Contract, and other limitations or exclusions may be listed in other sections of your Contract. Reading this Schedule by itself could give you an inaccurate impression of the terms of your coverage. This Schedule must be read with the rest of your Contract. Prior authorization may be required for specific services. PPO Plan Benefits BENEFIT CATEGORIES AND COST SHARING Platinum Premier PPO 500 PPO Member pays Participating Providers Non-Participating Providers Annual () Individual: $500 Individual: $5,000 Family: $1,000 Family: $10,000 Coinsurance (Coinsurance) 0% 40% Out-of-Pocket Maximum Individual: $1,500 Individual: $10,000 Family: $3,000 Family: $20,000 AMBULATORY SERVICES Office Visit Primary Care Physician $15 Copay /Coinsurance Specialist $30 Copay /Coinsurance Chiropractic Care $30 Copay /Coinsurance Limited to 20 visits per benefit year Surgery Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance Free-Standing Facility /Coinsurance Outpatient /Coinsurance Outpatient Facility and /Coinsurance Physician Services Hospice /Coinsurance Home Health Care /Coinsurance Limited to 60 visits per benefit year Skilled Nursing Facility /Coinsurance Limited to 120 days per benefit year EMERGENCY CARE Convenience Care* $30 Copay /Coinsurance Urgent Care $30 Copay $30 Copay Emergency Room Care $150 Copay $150 Copay

7 Emergency Advanced Imaging / High Tech Radiology Emergency Transportation/ Ambulance HOSPITALIZATION Inpatient Services /Coinsurance Inpatient Physician and Surgical /Coinsurance Services MATERNITY AND NEWBORN CARE Prenatal Office Visits $0 /Coinsurance Physician Charges, Prenatal, /Coinsurance Postnatal, Ultrasound, Delivery Outpatient Ultrasound /Coinsurance All Inpatient Services/Facility Charges /Coinsurance MENTAL HEALTH/SUBSTANCE ABUSE DISORDER SERVICES INCLUDING BEHAVIORAL HEALTH MANAGEMENT Office $30 Copay /Coinsurance Outpatient and Partial /Coinsurance Hospitalization Inpatient /Coinsurance REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES Outpatient Rehabilitation /Coinsurance Services PT/OT limited to 30 combined visits per benefit year ST limited to 30 visits per benefit year Habilitation Services /Coinsurance Limited to 30 visits per benefit year Durable Medical Equipment /Coinsurance Limited to once every 2 years for irreparable damage and/or normal wear LAB SERVICES Lab/Radiology Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance Outpatient /Coinsurance Diagnostic Mammogram Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance Free-Standing Facility /Coinsurance Outpatient /Coinsurance Advanced Imaging / High Tech Radiology Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance

8 Free-Standing Facility /Coinsurance Outpatient /Coinsurance PREVENTION/WELLNESS Preventive Care/Screening/ $0 /Coinsurance Immunization Preventive/Screening Limited to once per benefit year Mammogram Primary Care Physician s Office $0 /Coinsurance Specialist s Office $0 /Coinsurance Free-Standing Facility $0 /Coinsurance Outpatient $0 /Coinsurance PEDIATRIC SERVICES INCLUDING ORAL AND VISION CARE Pediatric Dental Care Type Coverage In & Out Preventive & Diagnostic Exams I 100% Cleanings I 100% X-rays I 100% Fluoride I 100% Sealants I 100% Basic Space Maintainers II 50% Fillings II 50% Adjustments to Dentures II 50% Anesthesia II 50% General Services II 50% Major Crowns III 50% Inlays III 50% Onlays III 50% Dentures III 50% Bridges III 50% Endo III 50% Perio III 50% Oral Surgery III 50% Implants III 50% Orthodontia IV 50% OOP Max Pediatric Vision Care Vision Screening for Children Eye Glasses for Children PRESCRIPTION DRUGS & OOP Max combined with medical, deductible does not apply to preventive & diagnostic services One routine eye examination per year One pair of standard eyeglass lenses or contact lenses per year; one frame every year Pharmacy Tier 1A: Lower Cost Preferred Generic Drugs No Rx Retail $3 / Mail Order $9

9 Tier 1: Preferred Generic Drugs Retail $10 / Mail Order $20 Tier 2: Preferred Brand Drugs Retail $35 / Mail Order $87.50 Tier 3: Non-Preferred Retail $60 / Mail Order $180 Generic/Brand Drugs Tier 4: Preferred Specialty Drugs Preferred Pharmacy $150 minimum or 20% with a max of $300 Tier 5: Non-Preferred Specialty Preferred Pharmacy 40% Coinsurance Drugs Vision Services Vision One Eyecare Program: Receive immediate savings on all eyecare needs--discounts on frames, lenses, disposable contacts, and even LASIK surgery--at participating providers through the EyeMed Vision Care network. PRECERTIFICATION REQUIREMENT When using a nonparticipating provider, the member must obtain precertification of nonemergency hospital and other facility (e.g., skilled nursing facilities, rehabilitation facilities, drug and alcohol treatment facilities) admissions, outpatient surgery and certain other services as stated in the Group Contract. If these services or admissions are not precertified and the service is not medically necessary, the member may be responsible for 100% of the cost of the services. LIFETIME MAXIMUM Unlimited This is not a contract. It is intended solely to provide you with an overview of the plan. Complete details of benefits, terms and exclusions are governed by your Group Contract. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have questions call us at in Central/Eastern Pennsylvania, and in Western Pennsylvania and Ohio. Benefits are administered on a contract year basis. Coinsurance is based on Eligible Charges as defined in your Certificate of Insurance. For non-participating providers, Eligible Charges are based on the lesser of the provider's billed charges or our Out-of-Network Rate, which is defined in your Certificate of Insurance. In addition to your copay or coinsurance, you are responsible for paying nonparticipating providers the difference between our out-of-network rate and their actual charge for nonemergency services. Your outof-pocket costs for nonemergency care from nonparticipating providers may be substantial. This document neither affirmatively nor negatively amends, extends, or alters the terms of or the coverage afforded by policy referenced herein *Convenience Care A condition that requires Convenience Care is an unexpected illness or injury that does not constitute an Emergency Medical Condition, but requires medical attention when you cannot see your family doctor right away. Convenience Care Centers are also useful for flu shots, vaccinations, and other shots

10 Preferred Provider Organization Underwritten by HealthAssurance Pennsylvania, Inc. This Schedule of Benefits, Covered Services, and Exclusions is part of your Individual Member Contract but does not replace it. Many words are defined elsewhere in the Contract, and other limitations or exclusions may be listed in other sections of your Contract. Reading this Schedule by itself could give you an inaccurate impression of the terms of your coverage. This Schedule must be read with the rest of your Contract. Prior authorization may be required for specific services. BENEFIT CATEGORIES AND COST SHARING Gold Premier PPO $25/$75 PPO Plan PPO Benefits Member pays Participating Non-Participating Providers Providers Annual () Individual: $0 Individual: $5,000 Family: $0 Family: $10,000 Coinsurance (Coinsurance) 0% 30% Out-of-Pocket Maximum Individual: $6,350 Individual: $10,000 Family: $12,700 Family: $20,000 AMBULATORY SERVICES Office Visit Primary Care Physician $25 Copay /Coinsurance Specialist $75 Copay /Coinsurance Chiropractic Care $75 Copay /Coinsurance Limited to 20 visits per benefit year Surgery Primary Care Physician s Office $250 Copay /Coinsurance Specialist s Office $250 Copay /Coinsurance Free-Standing Facility $250 Copay /Coinsurance Outpatient $500 Copay /Coinsurance Outpatient Facility and $75 Copay /Coinsurance Physician Services Hospice $75 Copay /Coinsurance Home Health Care $75 Copay /Coinsurance Limited to 60 visits per benefit year Skilled Nursing Facility $1000 Copay/Admit /Coinsurance Limited to 120 days per benefit year EMERGENCY CARE Convenience Care* $25 Copay /Coinsurance Urgent Care $75 Copay $75 Copay Emergency Room Care $300 Copay $300 Copay

11 Emergency Advanced Imaging / High Tech Radiology Emergency Transportation/ Ambulance Copay waived if admitted $300 Copay $300 Copay $300 Copay $300 Copay HOSPITALIZATION Inpatient Services $500 Copay / Admit /Coinsurance Inpatient Physician and $0 /Coinsurance Surgical Services MATERNITY AND NEWBORN CARE Prenatal Office Visits $0 /Coinsurance Physician Charges, Prenatal, $0 /Coinsurance Postnatal, Ultrasound, Delivery Outpatient Ultrasound $75 Copay /Coinsurance All Inpatient Services/Facility Charges $500 Copay / Admit /Coinsurance MENTAL HEALTH/SUBSTANCE ABUSE DISORDER SERVICES INCLUDING BEHAVIORAL HEALTH MANAGEMENT Office $75 Copay /Coinsurance Outpatient and Partial $75 Copay /Coinsurance Hospitalization Inpatient $500 Copay / Admit /Coinsurance REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES Outpatient Rehabilitation Services $75 Copay /Coinsurance PT/OT limited to 30 combined visits per benefit year ST limited to 30 visits per benefit year Habilitation Services $75 Copay /Coinsurance Limited to 30 visits per benefit year Durable Medical Equipment 50% Coinsurance /50%Coinsurance Limited to once every 2 years for irreparable damage and/or normal wear LAB SERVICES Lab/Radiology Primary Care Physician s Office Included in Office /Coinsurance Visit Specialist s Office Included in Office /Coinsurance Visit Outpatient $25 Copay /Coinsurance Diagnostic Mammogram Primary Care Physician s Office Included in Office /Coinsurance Visit Specialist s Office Included in Office /Coinsurance Visit Free-Standing Facility $25 Copay /Coinsurance

12 Outpatient $25 Copay /Coinsurance Advanced Imaging / High Tech Radiology Primary Care Physician s Office $500 Copay /Coinsurance Specialist s Office $500 Copay /Coinsurance Free-Standing Facility $500 Copay /Coinsurance Outpatient $500 Copay /Coinsurance PREVENTION/WELLNESS Preventive Care/Screening/ $0 /Coinsurance Immunization Preventive/Screening Limited to once per benefit year Mammogram Primary Care Physician s Office $0 /Coinsurance Specialist s Office $0 /Coinsurance Free-Standing Facility $0 /Coinsurance Outpatient $0 /Coinsurance PEDIATRIC SERVICES INCLUDING ORAL AND VISION CARE Pediatric Dental Care Type Coverage In & Out Preventive & Diagnostic Exams I 100% Cleanings I 100% X-rays I 100% Fluoride I 100% Sealants I 100% Basic Space Maintainers II 50% Fillings II 50% Adjustments to Dentures II 50% Anesthesia II 50% General Services II 50% Major Crowns III 50% Inlays III 50% Onlays III 50% Dentures III 50% Bridges III 50% Endo III 50% Perio III 50% Oral Surgery III 50% Implants III 50% Orthodontia IV 50% OOP Max Pediatric Vision Care Vision Screening for Children & OOP Max combined with medical, deductible does not apply to preventive & diagnostic services One routine eye examination per year

13 Eye Glasses for Children One pair of standard eyeglass lenses or contact lenses per year; one frame every year PRESCRIPTION DRUGS Pharmacy No RX Tier 1A: Lower Cost Preferred Retail $3 / Mail Order $9 Generic Drugs Tier 1: Preferred Generic Drugs Retail $10 / Mail Order $20 Tier 2: Preferred Brand Drugs Retail $40 / Mail Order $100 Tier 3: Non-Preferred Retail $70 / Mail Order $210 Generic/Brand Drugs Tier 4: Preferred Specialty Drugs Preferred Pharmacy $150 minimum or 20% with a max of $300 Tier 5: Non-Preferred Specialty Preferred Pharmacy 40% Coinsurance Drugs Vision Services Vision One Eyecare Program: Receive immediate savings on all eyecare needs--discounts on frames, lenses, disposable contacts, and even LASIK surgery--at participating providers through the EyeMed Vision Care network. PRECERTIFICATION REQUIREMENT When using a nonparticipating provider, the member must obtain precertification of nonemergency hospital and other facility (e.g., skilled nursing facilities, rehabilitation facilities, drug and alcohol treatment facilities) admissions, outpatient surgery and certain other services as stated in the Group Contract. If these services or admissions are not precertified and the service is not medically necessary, the member may be responsible for 100% of the cost of the services. LIFETIME MAXIMUM Unlimited This is not a contract. It is intended solely to provide you with an overview of the plan. Complete details of benefits, terms and exclusions are governed by your Group Contract. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have questions call us at in Central/Eastern Pennsylvania, and in Western Pennsylvania and Ohio. Benefits are administered on a contract year basis. Coinsurance is based on Eligible Charges as defined in your Certificate of Insurance. For non-participating providers, Eligible Charges are based on the lesser of the provider's billed charges or our Out-of-Network Rate, which is defined in your Certificate of Insurance. In addition to your copay or coinsurance, you are responsible for paying nonparticipating providers the difference between our out-of-network rate and their actual charge for nonemergency services. Your outof-pocket costs for nonemergency care from nonparticipating providers may be substantial. This document neither affirmatively nor negatively amends, extends, or alters the terms of or the coverage afforded by policy referenced herein *Convenience Care A condition that requires Convenience Care is an unexpected illness or injury that does not constitute an Emergency Medical Condition, but requires medical attention when you cannot see your family doctor right away. Convenience Care Centers are also useful for flu shots, vaccinations, and other shots

14 Preferred Provider Organization Underwritten by HealthAssurance Pennsylvania, Inc. This Schedule of Benefits, Covered Services, and Exclusions is part of your Individual Member Contract but does not replace it. Many words are defined elsewhere in the Contract, and other limitations or exclusions may be listed in other sections of your Contract. Reading this Schedule by itself could give you an inaccurate impression of the terms of your coverage. This Schedule must be read with the rest of your Contract. Prior authorization may be required for specific services. PPO Plan Benefits BENEFIT CATEGORIES AND COST SHARING Gold Premier PPO 1000 PPO Member pays Participating Providers Non-Participating Providers Annual () Individual: $1,000 Individual: $5,000 Family: $2,000 Family: $10,000 Coinsurance (Coinsurance) 0% 40% Out-of-Pocket Maximum Individual: $3,000 Individual: $10,000 Family: $6,000 Family: $20,000 AMBULATORY SERVICES Office Visit Primary Care Physician $25 Copay /Coinsurance Specialist $50 Copay /Coinsurance Chiropractic Care $50 Copay /Coinsurance Limited to 20 visits per benefit year Surgery Primary Care Physician s Office /$150 Copay /Coinsurance Specialist s Office /$150 Copay /Coinsurance Free-Standing Facility /$150 Copay /Coinsurance Outpatient /$150 Copay /Coinsurance Outpatient Facility and /$150 Copay /Coinsurance Physician Services Hospice /Coinsurance Home Health Care /Coinsurance Limited to 60 visits per benefit year Skilled Nursing Facility /Coinsurance Limited to 120 days per benefit year EMERGENCY CARE Convenience Care* $50 Copay /Coinsurance Urgent Care $75 Copay $75 Copay Emergency Room Care $200 Copay $200 Copay

15 Emergency Advanced Imaging / High Tech Radiology Emergency Transportation/ Ambulance HOSPITALIZATION Copay waived if admitted Inpatient Services /Coinsurance Inpatient Physician and Surgical /Coinsurance Services MATERNITY AND NEWBORN CARE Prenatal Office Visits $0 /Coinsurance Physician Charges, Prenatal, /Coinsurance Postnatal, Ultrasound, Delivery Outpatient Ultrasound /Coinsurance All Inpatient Services/Facility Charges /Coinsurance MENTAL HEALTH/SUBSTANCE ABUSE DISORDER SERVICES INCLUDING BEHAVIORAL HEALTH MANAGEMENT Office $50 Copay /Coinsurance Outpatient and Partial /Coinsurance Hospitalization Inpatient /Coinsurance REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES Outpatient Rehabilitation /Coinsurance Services PT/OT limited to 30 combined visits per benefit year ST limited to 30 visits per benefit year Habilitation Services /Coinsurance Limited to 30 visits per benefit year Durable Medical Equipment /Coinsurance Limited to once every 2 years for irreparable damage and/or normal wear LAB SERVICES Lab/Radiology Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance Outpatient /Coinsurance Diagnostic Mammogram Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance Free-Standing Facility /Coinsurance Outpatient /Coinsurance Advanced Imaging / High Tech Radiology Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance

16 Free-Standing Facility /Coinsurance Outpatient /Coinsurance PREVENTION/WELLNESS Preventive Care/Screening/ $0 /Coinsurance Immunization Preventive/Screening Limited to once per benefit year Mammogram Primary Care Physician s Office $0 /Coinsurance Specialist s Office $0 /Coinsurance Free-Standing Facility $0 /Coinsurance Outpatient $0 /Coinsurance PEDIATRIC SERVICES INCLUDING ORAL AND VISION CARE Pediatric Dental Care Type Coverage In & Out Preventive & Diagnostic Exams I 100% Cleanings I 100% X-rays I 100% Fluoride I 100% Sealants I 100% Basic Space Maintainers II 50% Fillings II 50% Adjustments to Dentures II 50% Anesthesia II 50% General Services II 50% Major Crowns III 50% Inlays III 50% Onlays III 50% Dentures III 50% Bridges III 50% Endo III 50% Perio III 50% Oral Surgery III 50% Implants III 50% Orthodontia IV 50% OOP Max Pediatric Vision Care Vision Screening for Children Eye Glasses for Children PRESCRIPTION DRUGS & OOP Max combined with medical, deductible does not apply to preventive & diagnostic services One routine eye examination per year One pair of standard eyeglass lenses or contact lenses per year; one frame every year Pharmacy Tier 1A: Lower Cost Preferred Generic Drugs No RX $3,350 Rx OOP Max Retail $3 / Mail Order $9

17 Tier 1: Preferred Generic Drugs Retail $10 / Mail Order $20 Tier 2: Preferred Brand Drugs Retail $35 / Mail Order $87.50 Tier 3: Non-Preferred Retail $60 / Mail Order $180 Generic/Brand Drugs Tier 4: Preferred Specialty Drugs Preferred Pharmacy $150 minimum or 20% with a max of $300 Tier 5: Non-Preferred Specialty Preferred Pharmacy 40% Coinsurance Drugs Vision Services Vision One Eyecare Program: Receive immediate savings on all eyecare needs--discounts on frames, lenses, disposable contacts, and even LASIK surgery--at participating providers through the EyeMed Vision Care network. PRECERTIFICATION REQUIREMENT When using a nonparticipating provider, the member must obtain precertification of nonemergency hospital and other facility (e.g., skilled nursing facilities, rehabilitation facilities, drug and alcohol treatment facilities) admissions, outpatient surgery and certain other services as stated in the Group Contract. If these services or admissions are not precertified and the service is not medically necessary, the member may be responsible for 100% of the cost of the services. LIFETIME MAXIMUM Unlimited This is not a contract. It is intended solely to provide you with an overview of the plan. Complete details of benefits, terms and exclusions are governed by your Group Contract. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have questions call us at in Central/Eastern Pennsylvania, and in Western Pennsylvania and Ohio. Benefits are administered on a contract year basis. Coinsurance is based on Eligible Charges as defined in your Certificate of Insurance. For non-participating providers, Eligible Charges are based on the lesser of the provider's billed charges or our Out-of-Network Rate, which is defined in your Certificate of Insurance. In addition to your copay or coinsurance, you are responsible for paying nonparticipating providers the difference between our out-of-network rate and their actual charge for nonemergency services. Your outof-pocket costs for nonemergency care from nonparticipating providers may be substantial. This document neither affirmatively nor negatively amends, extends, or alters the terms of or the coverage afforded by policy referenced herein *Convenience Care A condition that requires Convenience Care is an unexpected illness or injury that does not constitute an Emergency Medical Condition, but requires medical attention when you cannot see your family doctor right away. Convenience Care Centers are also useful for flu shots, vaccinations, and other shots

18 Preferred Provider Organization Underwritten by HealthAssurance Pennsylvania, Inc. This Schedule of Benefits, Covered Services, and Exclusions is part of your Individual Member Contract but does not replace it. Many words are defined elsewhere in the Contract, and other limitations or exclusions may be listed in other sections of your Contract. Reading this Schedule by itself could give you an inaccurate impression of the terms of your coverage. This Schedule must be read with the rest of your Contract. Prior authorization may be required for specific services. PPO Plan Benefits BENEFIT CATEGORIES AND COST SHARING Gold Premier PPO 1500 PPO Member pays Participating Providers Non-Participating Providers Annual () Individual: $1,500 Individual: $5,000 Family: $3,000 Family: $10,000 Coinsurance (Coinsurance) 0% 40% Out-of-Pocket Maximum Individual: $6,000 Individual: $10,000 Family: $12,000 Family: $20,000 AMBULATORY SERVICES Office Visit Primary Care Physician $15 Copay /Coinsurance Specialist $50 Copay /Coinsurance Chiropractic Care $50 Copay /Coinsurance Limited to 20 visits per benefit year Surgery Primary Care Physician s Office /$150 Copay /Coinsurance Specialist s Office /$150 Copay /Coinsurance Free-Standing Facility /$150 Copay /Coinsurance Outpatient /$150 Copay /Coinsurance Outpatient Facility and /$150 Copay /Coinsurance Physician Services Hospice /Coinsurance Home Health Care /Coinsurance Limited to 60 visits per benefit year Skilled Nursing Facility /Coinsurance Limited to 120 days per benefit year EMERGENCY CARE Convenience Care* $50 Copay /Coinsurance Urgent Care $75 Copay $75 Copay

19 Emergency Room Care $300 Copay $300 Copay Copay waived if admitted Emergency Advanced Imaging / High Tech Radiology Emergency Transportation/ Ambulance HOSPITALIZATION Inpatient Services / $250 Copay Inpatient Physician and Surgical Services /Coinsurance /Coinsurance MATERNITY AND NEWBORN CARE Prenatal Office Visits $0 /Coinsurance Physician Charges, Prenatal, /Coinsurance Postnatal, Ultrasound, Delivery Outpatient Ultrasound /Coinsurance All Inpatient Services/Facility Charges /Coinsurance MENTAL HEALTH/SUBSTANCE ABUSE DISORDER SERVICES INCLUDING BEHAVIORAL HEALTH MANAGEMENT Office $50 Copay /Coinsurance Outpatient and Partial /Coinsurance Hospitalization Inpatient /Coinsurance REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES Outpatient Rehabilitation / $50 Copay /Coinsurance Services PT/OT limited to 30 combined visits per benefit year ST limited to 30 visits per benefit year Habilitation Services / $50 Copay /Coinsurance Limited to 30 visits per benefit year Durable Medical Equipment /Coinsurance Limited to once every 2 years for irreparable damage and/or normal wear LAB SERVICES Lab/Radiology Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance Outpatient /Coinsurance Diagnostic Mammogram Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance Free-Standing Facility /Coinsurance Outpatient /Coinsurance Advanced Imaging / High Tech Radiology

20 Primary Care Physician s Office /Coinsurance Specialist s Office /Coinsurance Free-Standing Facility /Coinsurance Outpatient /Coinsurance PREVENTION/WELLNESS Preventive Care/Screening/ $0 /Coinsurance Immunization Preventive/Screening Limited to once per benefit year Mammogram Primary Care Physician s Office $0 /Coinsurance Specialist s Office $0 /Coinsurance Free-Standing Facility $0 /Coinsurance Outpatient $0 /Coinsurance PEDIATRIC SERVICES INCLUDING ORAL AND VISION CARE Pediatric Dental Care Type Coverage In & Out Preventive & Diagnostic Exams I 100% Cleanings I 100% X-rays I 100% Fluoride I 100% Sealants I 100% Basic Space Maintainers II 50% Fillings II 50% Adjustments to Dentures II 50% Anesthesia II 50% General Services II 50% Major Crowns III 50% Inlays III 50% Onlays III 50% Dentures III 50% Bridges III 50% Endo III 50% Perio III 50% Oral Surgery III 50% Implants III 50% Orthodontia IV 50% OOP Max Pediatric Vision Care Vision Screening for Children Eye Glasses for Children PRESCRIPTION DRUGS & OOP Max combined with medical, deductible does not apply to preventive & diagnostic services One routine eye examination per year One pair of standard eyeglass lenses or contact lenses per year; one frame every year Pharmacy No RX

21 Tier 1A: Lower Cost Preferred Retail $3 / Mail Order $9 Generic Drugs Tier 1: Preferred Generic Drugs Retail $10 / Mail Order $20 Tier 2: Preferred Brand Drugs Retail $40 / Mail Order $100 Tier 3: Non-Preferred Retail $70 / Mail Order $210 Generic/Brand Drugs Tier 4: Preferred Specialty Preferred Pharmacy $150 minimum or 20% with a Drugs max of $300 Tier 5: Non-Preferred Specialty Preferred Pharmacy 40% Coinsurance Drugs Vision Services Vision One Eyecare Program: Receive immediate savings on all eyecare needs-- discounts on frames, lenses, disposable contacts, and even LASIK surgery--at participating providers through the EyeMed Vision Care network. PRECERTIFICATION REQUIREMENT When using a nonparticipating provider, the member must obtain precertification of nonemergency hospital and other facility (e.g., skilled nursing facilities, rehabilitation facilities, drug and alcohol treatment facilities) admissions, outpatient surgery and certain other services as stated in the Group Contract. If these services or admissions are not precertified and the service is not medically necessary, the member may be responsible for 100% of the cost of the services. LIFETIME MAXIMUM Unlimited This is not a contract. It is intended solely to provide you with an overview of the plan. Complete details of benefits, terms and exclusions are governed by your Group Contract. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have questions call us at in Central/Eastern Pennsylvania, and in Western Pennsylvania and Ohio. Benefits are administered on a contract year basis. Coinsurance is based on Eligible Charges as defined in your Certificate of Insurance. For non-participating providers, Eligible Charges are based on the lesser of the provider's billed charges or our Out-of-Network Rate, which is defined in your Certificate of Insurance. In addition to your copay or coinsurance, you are responsible for paying nonparticipating providers the difference between our out-of-network rate and their actual charge for nonemergency services. Your out-of-pocket costs for nonemergency care from nonparticipating providers may be substantial. This document neither affirmatively nor negatively amends, extends, or alters the terms of or the coverage afforded by policy referenced herein *Convenience Care A condition that requires Convenience Care is an unexpected illness or injury that does not constitute an Emergency Medical Condition, but requires medical attention when you cannot see your family doctor right away. Convenience Care Centers are also useful for flu shots, vaccinations, and other shots

22 Preferred Provider Organization Underwritten by HealthAssurance Pennsylvania, Inc. This Schedule of Benefits, Covered Services, and Exclusions is part of your Individual Member Contract but does not replace it. Many words are defined elsewhere in the Contract, and other limitations or exclusions may be listed in other sections of your Contract. Reading this Schedule by itself could give you an inaccurate impression of the terms of your coverage. This Schedule must be read with the rest of your Contract. Prior authorization may be required for specific services. PPO Plan Benefits BENEFIT CATEGORIES AND COST SHARING Gold Classic PPO 1000 PPO Member pays Participating Providers Non-Participating Providers Annual () Individual: $1,000 Individual: $5,000 Family: $2,000 Family: $10,000 Coinsurance (Coinsurance) 10% 40% Out-of-Pocket Maximum Individual: $5,500 Individual: $10,000 Family: $11,000 Family: $20,000 AMBULATORY SERVICES Office Visit Primary Care Physician $30 Copay /Coinsurance Specialist $60 Copay /Coinsurance Chiropractic Care $60 Copay /Coinsurance Limited to 20 visits per benefit year Surgery Primary Care Physician s Office /Coinsurance /Coinsurance Specialist s Office /Coinsurance /Coinsurance Free-Standing Facility /Coinsurance /Coinsurance Outpatient /Coinsurance /Coinsurance Outpatient Facility and /Coinsurance /Coinsurance Physician Services Hospice /Coinsurance /Coinsurance Home Health Care /Coinsurance /Coinsurance Limited to 60 visits per benefit year Skilled Nursing Facility /Coinsurance /Coinsurance Limited to 120 days per benefit year EMERGENCY CARE Convenience Care* $60 Copay /Coinsurance Urgent Care $60 Copay $60 Copay Emergency Room Care $250 Copay $250 Copay

23 Emergency Advanced Imaging / High Tech Radiology Emergency Transportation/ Ambulance Copay waived if admitted /Coinsurance / 10% Coinsurance /Coinsurance / 10% Coinsurance HOSPITALIZATION Inpatient Services /Coinsurance /Coinsurance Inpatient Physician and Surgical /Coinsurance /Coinsurance Services MATERNITY AND NEWBORN CARE Prenatal Office Visits $0 /Coinsurance Physician Charges, Prenatal, /Coinsurance /Coinsurance Postnatal, Ultrasound, Delivery Outpatient Ultrasound /Coinsurance /Coinsurance All Inpatient Services/Facility Charges /Coinsurance /Coinsurance MENTAL HEALTH/SUBSTANCE ABUSE DISORDER SERVICES INCLUDING BEHAVIORAL HEALTH MANAGEMENT Office $60 Copay /Coinsurance Outpatient and Partial /Coinsurance /Coinsurance Hospitalization Inpatient /Coinsurance /Coinsurance REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES Outpatient Rehabilitation /Coinsurance /Coinsurance Services PT/OT limited to 30 combined visits per benefit year ST limited to 30 visits per benefit year Habilitation Services /Coinsurance /Coinsurance Limited to 30 visits per benefit year Durable Medical Equipment /Coinsurance /Coinsurance Limited to once every 2 years for irreparable damage and/or normal wear LAB SERVICES Lab/Radiology Primary Care Physician s Office /Coinsurance /Coinsurance Specialist s Office /Coinsurance /Coinsurance Outpatient /Coinsurance /Coinsurance Diagnostic Mammogram Primary Care Physician s Office /Coinsurance /Coinsurance Specialist s Office /Coinsurance /Coinsurance Free-Standing Facility /Coinsurance /Coinsurance Outpatient /Coinsurance /Coinsurance Advanced Imaging / High Tech Radiology Primary Care Physician s Office /Coinsurance /Coinsurance Specialist s Office /Coinsurance /Coinsurance

24 Free-Standing Facility /Coinsurance /Coinsurance Outpatient /Coinsurance /Coinsurance PREVENTION/WELLNESS Preventive Care/Screening/ $0 /Coinsurance Immunization Preventive/Screening Limited to once per benefit year Mammogram Primary Care Physician s Office $0 /Coinsurance Specialist s Office $0 /Coinsurance Free-Standing Facility $0 /Coinsurance Outpatient $0 /Coinsurance PEDIATRIC SERVICES INCLUDING ORAL AND VISION CARE Pediatric Dental Care Type Coverage In & Out Preventive & Diagnostic Exams I 100% Cleanings I 100% X-rays I 100% Fluoride I 100% Sealants I 100% Basic Space Maintainers II 50% Fillings II 50% Adjustments to Dentures II 50% Anesthesia II 50% General Services II 50% Major Crowns III 50% Inlays III 50% Onlays III 50% Dentures III 50% Bridges III 50% Endo III 50% Perio III 50% Oral Surgery III 50% Implants III 50% Orthodontia IV 50% OOP Max Pediatric Vision Care Vision Screening for Children Eye Glasses for Children PRESCRIPTION DRUGS & OOP Max combined with medical, deductible does not apply to preventive & diagnostic services One routine eye examination per year One pair of standard eyeglass lenses or contact lenses per year; one frame every year Pharmacy Tier 1A: Lower Cost Preferred Generic Drugs No Rx Retail $3 / Mail Order $9

25 Tier 1: Preferred Generic Drugs Retail $10 / Mail Order $20 Tier 2: Preferred Brand Drugs Retail $35 / Mail Order $87.50 Tier 3: Non-Preferred Retail $60 / Mail Order $180 Brand/Generic Drugs Tier 4: Preferred Specialty Drugs Preferred Pharmacy $150 minimum or 20% with a max of $300 Tier 5: Non-Preferred Specialty Preferred Pharmacy 40% Coinsurance Drugs Vision Services Vision One Eyecare Program: Receive immediate savings on all eyecare needs--discounts on frames, lenses, disposable contacts, and even LASIK surgery--at participating providers through the EyeMed Vision Care network. PRECERTIFICATION REQUIREMENT When using a nonparticipating provider, the member must obtain precertification of nonemergency hospital and other facility (e.g., skilled nursing facilities, rehabilitation facilities, drug and alcohol treatment facilities) admissions, outpatient surgery and certain other services as stated in the Group Contract. If these services or admissions are not precertified and the service is not medically necessary, the member may be responsible for 100% of the cost of the services. LIFETIME MAXIMUM Unlimited This is not a contract. It is intended solely to provide you with an overview of the plan. Complete details of benefits, terms and exclusions are governed by your Group Contract. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have questions call us at in Central/Eastern Pennsylvania, and in Western Pennsylvania and Ohio. Benefits are administered on a contract year basis. Coinsurance is based on Eligible Charges as defined in your Certificate of Insurance. For non-participating providers, Eligible Charges are based on the lesser of the provider's billed charges or our Out-of-Network Rate, which is defined in your Certificate of Insurance. In addition to your copay or coinsurance, you are responsible for paying nonparticipating providers the difference between our out-of-network rate and their actual charge for nonemergency services. Your outof-pocket costs for nonemergency care from nonparticipating providers may be substantial. This document neither affirmatively nor negatively amends, extends, or alters the terms of or the coverage afforded by policy referenced herein *Convenience Care A condition that requires Convenience Care is an unexpected illness or injury that does not constitute an Emergency Medical Condition, but requires medical attention when you cannot see your family doctor right away. Convenience Care Centers are also useful for flu shots, vaccinations, and other shots

26 Preferred Provider Organization Underwritten by HealthAssurance Pennsylvania, Inc. This Schedule of Benefits, Covered Services, and Exclusions is part of your Individual Member Contract but does not replace it. Many words are defined elsewhere in the Contract, and other limitations or exclusions may be listed in other sections of your Contract. Reading this Schedule by itself could give you an inaccurate impression of the terms of your coverage. This Schedule must be read with the rest of your Contract. Prior authorization may be required for specific services. BENEFIT CATEGORIES AND COST SHARING Silver Premier PPO $25/$75 PPO Plan PPO Benefits Member pays Participating Non-Participating Providers Providers Annual () Individual: $0 Individual: $5,000 Family: $0 Family: $10,000 Coinsurance (Coinsurance) 0% 30% Out-of-Pocket Maximum Individual: $6,350 Individual: $10,000 Family: $12,700 Family: $20,000 AMBULATORY SERVICES Office Visit Primary Care Physician $25 Copay /Coinsurance Specialist $75 Copay /Coinsurance Chiropractic Care $75 Copay /Coinsurance Limited to 20 visits per benefit year Surgery Primary Care Physician s Office $1000 Copay /Coinsurance Specialist s Office $1000 Copay /Coinsurance Free-Standing Facility $1000 Copay /Coinsurance Outpatient $2000 Copay /Coinsurance Outpatient Facility and $75 Copay /Coinsurance Physician Services Hospice $75 Copay /Coinsurance Home Health Care $75 Copay /Coinsurance Limited to 60 visits per benefit year Skilled Nursing Facility $1000 Copay/Admit /Coinsurance Limited to 120 days per benefit year EMERGENCY CARE