PPO Option January 1, 2015 December 31, 2015

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1 COST SHARING LIFETIME LIMITS Calendar Year Deductible Individual Family Calendar Year Out-of-Pocket Maximum Individual Family None None $500 includes copays $1500 includes copays $100 $300 $1,000 includes deductibles and copays $3,000 includes deductibles and copays Coinsurance 100% Lifetime Maximum Unlimited Unlimited PROFESSIONAL SERVICES Primary Care Office Visit $15 copay Gynecology Office Visit $15 copay for Well Woman visit or $20 copay for all other visits Specialist Office Visit $20 copay Physical Therapy Office Visit 100% (120 visits combined with Occupational Therapy) (120 visits combined with Occupational Therapy) Speech Therapy Office Visit 100% no copay 60 visits (60 visits) Occupational Therapy Visit Chiropractic Office Visit 100% (120 visits combined with Physical Therapy) 100% (limited to 30 visit maximum combined in and out of network) Preauthorization not required. (120 visits) combined with Physical Therapy (limited to 30 visit maximum combined in and out of network) Preauthorization not required. Howard County Public School System Enrollment Guide for Retirees 27

2 PROFESSIONAL SERVICES (continued) Allergy Shots/Other Covered Injections 100% after copay Allergy Serum 100% after copay Allergy Testing Diagnostic tests Diagnostic tests performed by lab or other testing facility and billed separately from office visit PREVENTIVE CARE Covered as either a PCP or Specialist office visit Included with PCP or Specialist copayment 100% Well Child Visit/Immunization $15 copay Routine Adult Physical $15 copay Routine Gynecological Exam Routine Pap Smear $15 copay, one exam per calendar year 100% when included with routine gynecological exam. One exam per Routine Mammogram 100%. Baseline between age One per calendar year age 40 and over. PSA Testing One per calendar year for males age 40 and over, one exam per calendar year, when included with routine gynecological exam. One exam per. Baseline between age One per calendar year age 40 and over. 80%, no deductible. One per calendar year for males age 40 and over 28 Howard County Public School System Enrollment Guide for Retirees

3 INPATIENT HOSPITAL CARE (Preauthorization Required) Room and Board 100% Pre-authorization required. Preauthorization required. Physician/Surgical Services 100% Anesthesia Services 100% Intensive Care Unit/Critical Care Unit 100% Maternity/Nursery/Birthing Center 100% Skilled Nursing/Rehab Facility Care (Preauthorization Required) 100% limited to 120 days per limited to 120 days per Dialysis/Radiation/Chemotherapy 100% Hospice 100% Physical/Speech/ Occupational Therapy OUTPATIENT HOSPITAL CARE 100% Surgical/Anesthesia Services 100% Dialysis/Radiation/Chemotherapy 100% Outpatient Diagnostic Services 100% MATERNITY/INFERTILITY SERVICES 1st prenatal visit 100% after copay Pre-and Postnatal care and delivery 100% Routine nursery care 100% Sterilization/Reverse Sterilization requires preauthorization Artificial Insemination (AI) In Vitro Fertilization (IVF) maximum of 3 IVF attempts/ lifetime (Preauthorization Required) 100% Reverse Sterilization is not covered 100%, (subject to applicable copay) preauthorization required. Limited to 6 courses of treatment per lifetime. 100%, (subject to applicable copay) preauthorization required.. Reverse Sterilization is not covered, preauthorization required. Limited to 6 courses of treatment per lifetime., preauthorization required. Howard County Public School System Enrollment Guide for Retirees 29

4 MEDICAL EMERGENCIES (USE OF ER) Emergency Room 100% after $50 ER copay (waived if admitted) 100% after $50 ER copay (waived if admitted) Urgent Care Center 100% after $25 copay MEDICAL EQUIPMENT/SUPPLIES Durable Medical Equipment 100% Prosthetic Devices (Pre-authorization required) 100% Orthopedic Devices 100% Foot Orthotics (Subject to medical necessity) 100% MENTAL HEALTH AND SUBSTANCE ABUSE (Preauthorization required for inpatient only) Mental Health: Inpatient Outpatient Substance Abuse: Inpatient Outpatient OTHER SERVICES 100% $20 copay 100% $20 copay Ambulance Ground 100% Kidney, Cornea Bone Marrow Transplants Air 100% Covered in full. The National Medical Excellence (NME) unit will arrange transplant services by a facility that is part of the Institutes of Excellence (IOE) transplant network. Ground: 100% no deductible. Non-emergency use 80% after deductible Air: 100% no deductible 30 Howard County Public School System Enrollment Guide for Retirees

5 OTHER SERVICES (continued) Heart, Heart-Lung, Lung, Pancreas, Liver Transplants Cardiac Rehabilitation Hearing Aids Acupuncture Vision (Routine eye exam) Covered in full. The National Medical Excellence (NME) unit will arrange transplant services by a facility that is part of the Institutes of Excellence (IOE) transplant network. 100% if performed in an outpatient hospital setting; 100% after copay in office setting or freestanding cardiac rehabilitation center Hearing aids: 100% to a maximum of $1,400 per ear during any 36 month period for a child up to age 19. Hearing exam: 100% after specialist copay. One exam every 12 months. Acupuncture therapy includes services provided by a licensed acupuncturist covered at 100% no copay subject to R&C Routine eye exam covered at 100% after $20 copay. One exam every 12 months. Hearing aids: to a maximum of $1,400 per ear during any 36 month period for a child up to age 19. Hearing exam: Not covered Acupuncture therapy includes services provided by a licensed acupuncturist covered at 100% no copay subject to R&C Not covered Howard County Public School System Enrollment Guide for Retirees 31

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