SCHEDULE OF BENEFITS

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1 SCHEDULE OF BENEFITS Premier HealthOne Bronze 5500 Health Maintenance Organization (HMO) Individual Certificate of Coverage This schedule of benefits (SOB) is part of your Certificate of Coverage (COC) but does not replace it. Many words are defined elsewhere in the COC, and other limitations or exclusions may be listed in other sections of the COC. This SOB lists Your cost sharing obligations and other important information that apply to the services you receive under Your Plan. You should review this SOB to become familiar with Your cost sharing obligations and any limits that apply to the services. If You have any questions about this COC or want more information about Your benefits or Us, contact Member Services at the phone number on the back of Your Member ID Card or write to: 110 N. Main Street Suite 1200 Dayton, OH Benefits Benefit Year Deductible Per individual $5,500 Per family If an individual member meets the individual deductible, the plan will begin to pay benefits for that specific member, even if the family deductible is not met Coinsurance (Percent paid by You) $11,000 % Coinsurance, after Deductible 30% Benefit Year Out-of-Pocket Limit Per individual $6,600 Per family If an individual member meets the individual out-of-pocket limit, the plan will pay benefits for that specific member, even if the family out-of-pocket limit is not met Covered Services $13,200 PHP-IND-OH-HMO-SOB Bronze 5500

2 Benefits Preventive care Child health supervision services Periodic health examinations Annual gynecology examination Contraceptive benefits Prostate screening Illness or Injury Office visit After hours care Specialty care doctor office visit Allergy Treatment Allergy Testing Maternity Care Maternity care (prenatal/postnatal visits) Inpatient delivery and other maternity care services Complications of pregnancy Sterilization Emergency Room Services Life-threatening illness or serious accidental injury Non-emergency use of the emergency room Urgent care services Inpatient Services Daily room, board and general nursing care Physician services Assistant surgery Outpatient Services Surgery facility/hospital charges Advanced imaging and diagnostic services Physician services Assistant surgery Therapy Services Manipulation Therapy/Chiropractic Care (limit of 12 visits/year) Dialysis treatment $30 copay $30 copay $750 copay and $200 copay and Not Covered $75 copay $750 copay and PHP-IND-OH-HMO-SOB Bronze 5500

3 Benefits Habilitative services (limit of 20 visits/year for each outpatient physical rehabilitation service; limit of 20 hours/week for clinical therapeutic intervention) Outpatient rehabilitation services (combined limit of 116 visits/year for physical therapy, occupational therapy, speech therapy, respiratory therapy and cardiac rehabilitation) Cardiac rehabilitation (limit of 36 visits/year) Occupational therapy (limit of 20 visits/year) Physical therapy (limit of 20 visits/year) Respiratory therapy (limit of 20 visits/year) Speech therapy (limit of 20 visits/year) Chemotherapy and radiation Mental Health/Substance Abuse Services Inpatient services Partial hospitalization Intensive outpatient treatment or day treatment Outpatient treatment or individual or group treatment Residential treatment services Other Services Ambulance Breast cancer patient care Cancer clinical trials Clinical trial programs required by the Affordable Care Act Consultation services Dental services related to accidental injury ($3,000/occurrence) Diabetic equipment, education and supplies Durable medical equipment General anesthesia services Home health care (limit of 100 visits/year) Hospice care Infertility services Medical supplies Nutritional counseling Private duty nursing (limit of 90-] visits/year) $500 copay and $30 copay/visit and for other outpatient services $30 copay/visit and for other outpatient services $500 copay and PHP-IND-OH-HMO-SOB Bronze 5500

4 Benefits Prosthetics Appliances Reconstructive surgery Skilled nursing facility care (limit of 90 days/year) Temporomandibular or Craniomandibular Joint Disorder and Craniomandibular Jaw Disorder Telemedicine Vision correction (cataract or aphakia treatment) Transplant Services Organ transplants Unrelated donor searches for bone marrow/stem cell transplants Travel and lodging for organ transplants Pediatric Vision Services Eye exam for Children (Limit of 1 visit/year) Glasses or contacts (1 pair of glasses (lenses and frames) or contact lenses/year*) Prescription Drug - Certain preventive medications may be covered at no cost, please see formulary for more information Pharmacy Deductible Payable in accordance with the type of expense incurred and the place of service. ; Limit of up to $30,0000 per transplant ; Limit of up to $10,0000 per transplant No charge No charge *See Certificate of Coverage for limitations on glasses or contact lenses. Retail (up to 30-day supply) Mail Order (up to 90-day supply) Integrated with Medical Deductible (Except for generic drugs, must meet calendar year deductible before the plan begins to pay pharmacy benefits) Preferred Generic $15 copay *or less $37.50 copay *or less Non-preferred generic $25 copay *or less $62.50 copay *or less Preferred brand Non-preferred brand Specialty 30% coinsurance after 30% coinsurance after *There are situations where the cost of the drug could be less than your cost sharing. Please refer to the Prescription Drug benefit in Your Certificate of Coverage PHP-IND-OH-HMO-SOB Bronze 5500

5 Verification of Benefits Verification of benefits is available for Members or Providers on behalf of Members. You may call Member Services with a benefits inquiry during normal business hours, [7 a.m. to 7 p.m. eastern time Monday through Friday, and 8 a.m. to 3 p.m. on Saturdays]. Please remember that a benefits inquiry is NOT a verification of coverage of a specific medical procedure. Verification of benefits is NOT a guarantee of payment If the verified service requires Prior Authorization, please call [phone number] PHP-IND-OH-HMO-SOB Bronze 5500

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