Coventry Health Care of Missouri

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1 Small Group PPO Schedule of Benefits: Coventry Health Care of Missouri Plan ID#: Platinum Carelink from Coventry A (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain Covered Services. Refer to Your Certificate of Coverage (COC) for a detailed description of Covered Services and limitations or exclusions. To receive coverage according to Your In-Network level of benefits, all Covered Services, except for Emergency Services and those Authorized in advance by the Plan, must be performed by a Participating Provider in the Carelink from Coventry Product. Additionally, In-Network Specialist visits require a referral from your Carelink from Coventry Primary Care Physician. Services must be Medically Necessary as a condition of Coverage and not otherwise limited or excluded.some covered services may require Prior Authorization. Please refer to Your COC or contact Customer Service at the phone number listed on the back of Your ID card. Your Carelink from Coventry Physician is responsible for obtaining required Authorizations for In-Network services. BENEFIT AND SERVICES 1 Annual Deductible Total amount a plan member is required to pay each benefit year before he or she is eligible for certain Covered Services. Deductible amounts accumulate separately for In- and Out-of-Network benefits. The family is satisfied when all family members combine to meet the family amounts. The annual Deductible need only be met once per plan member per benefit year. In some cases, In-Network Deductible will not apply. Individual $0 Family $0 Individual $3,000 Family $6,000 2 Annual Out-of-Pocket Maximum Copayments, coinsurance, s and pharmacy apply to the out-ofpocket maximum. Out-of-pocket amounts accumulate separately for In- and Out-of-Network benefits. The family out-of-pocket amount is satisfied when all family members combine to meet the family out-of-pocket maximum amounts. The annual Out-of-Pocket Maximum need only be met once per plan member per benefit year.the following services do not apply to the outof-pocket maximum: charges above the Out-of-Network Rate and penalties for failure to Prior Authorize services. Individual $1,500 Family $3,000 Individual $6,000 Family $12,000 3 Maximum Lifetime Benefit Combined total of all benefits. 4 Physician Office Visit - Preventive Care Services include routine health assessment, telemedicine, well-child care, immunizations and injections, routine hearing and vision screening, prostate specific antigen testing, annual self-referred gynecological examination and pap smear, and mammogram screening and other preventive care services mandated by the Affordable Care Act. Consult Your Certificate of Coverage for more information. Unlimited For Primary Care Services per visit For Specialty Care Services per visit Unlimited For Primary Care Services No Deductible or Coinsurance for Immunizations through age 5 For Specialty Care Services No Deductible or Coinsurance for Immunizations through age 5 5 Physician Office Visit - Medical Services Services include diagnosis, consultation and treatment, telemedicine, adult immunizations, vision examination, surgery, diagnostic lab work, diagnostic radiology services, and allergy testing and treatment. Certain services require Prior Authorization. For Primary Care Services $25 For Primary Care Services For Specialty Care Services For Specialty Care Services MOSOBSGPPOCHL814 MO DOI Approved

2 6 E-visits BENEFIT AND SERVICES For Primary Care Services For Primary Care Services $0 For Specialty Care Services For Specialty Care Services $15 7 Chiropractic Services Coverage is provided for chiropractic services up to 26 visits per benefit year without Prior Authorization. Maximum benefit is an In- and Out-of-Network combined limit without Prior Authorization. $20 8 Emergency Room Services Coverage is provided for worldwide emergency health services as defined in the Certificate of Coverage. Includes facility and professional charges. 9 Ambulance Services Coverage is provided for Emergency Services as defined in the COC. Prior Authorization is required for non-emergent facility-to-facility ambulance transportation. $250 (Waived if patient is admitted) Co-insurance per occurrence $250 (Waived if patient is admitted) Co-insurance per occurrence after 10 Urgent Care Services Covered Service for urgent care services at participating alternate facilities both in and out of the Service Area. $75 $75 11 Maternity Care Office Visits Coverage for maternity care, include in prenatal, delivery, and post-natal care. $25 Co-pay first visit only 12 Maternity Care, Inpatient Hospital Covered Services include all pysician/facility services for mother and newborn(s), newborn nursery services, and semi-private room for a minimum of 48 hours (vaginal) and 96 (caesarian) following delivery. Inpatient stays beyond 48 (vaginal) / 96 (caesarian) require Prior Authorization. Newborn stay after mother's discharge is considered a separate admission. Note that For all related Maternity services, including outpatient observation stay, any applicable cost-share will be consistent with the type of services received. $0 Co-pay per admission 13 Outpatient Services and Diagnostic Procedures and Tests Coverage includes diagnostic procedures and tests, including but not limited to bone density testing, mammograms, radiation therapy and therapeutic treatments such as dialysis, inhalation, chemotherapy and lab and radiology not performed in the Physician s Office. Certain procedures and tests may be considered surgery, including but not limited to colonoscopy and endoscopy. Refer to the Outpatient Surgery section of Your COC for more information. Certain services require Prior Authorization. Co-insurance per visit 2 of billed charge penalty for failure MOSOBSGPPOCHL814 MO DOI Approved

3 BENEFIT AND SERVICES 14 High Technology Diagnostic Services, Tests, and Procedures Including, but not limited to: MRI, MRA, CT Scans, Thallium Scans, Nuclear Stress Tests, PET Scans, Echocardiograms (regardless of where service is performed). Requires Prior Authorization. $100 2 of billed charge penalty for failure 15 Outpatient Surgery Benefits are provided for Covered Services rendered at an outpatient hospital for free standing surgery center. Requires Prior Authorization. $100 2 of billed charge penalty for failure 16 Injectible Medications Requires Prior Authorization. Covered Service for Injectible Medication. Medications considered by the Plan to be Self-Injectible Medications are Covered under a Pharmacy Rider, if purchased. 17 Inpatient Hospital Services Coverage is provided for Medically Necessary Physician and surgeon services, semi-private room, operating room and related facilities, intensive and coronary care units, laboratory, x-rays, radiology services and procedures, medications and biologicals, anesthesia, short-term rehabilitation services, nursing care, meals and special diets. Inpatient alcoholism treatment is Covered the same as any other sickness. Requires Prior Authorization. Co-insurance per admission 18 Skilled Nursing Facility Coverage is provided in lieu of an inpatient hospital admission when Prior Authorized. Coverage is provided for a semi-private room. Prior Authorization is required. Limited to 90 days per benefit year. Co-pay per admission 19 Home Health Care Coverage is provided for home health care and/or home infusion therapy services provided in Your home when Prior Authorized. Home health care is limited to 90 days per benefit year. Private duty nursing provided in the home setting is limited to,000 per benefit year and $100,000 per lifetime. Co-insurance per visit 20 Hospice Covered for hospice services provided in Your home when Prior Authorized. Co-insurance per visit 21 Durable Medical Equipment Coverage is provided when services are Prior Authorized for equipment purchased in excess of 0 and for all rental equipment. Co-insurance of covered expenses Co-insurance of covered expenses after 2 of billed charge penalty for failure MOSOBSGPPOCHL814 MO DOI Approved

4 BENEFIT AND SERVICES 22 Prosthetics and Orthotics Coverage is provided when services are Prior Authorized for equipment purchased in excess of $10,000 and for all rental equipment. Co-insurance of covered expenses Co-insurance of covered expenses after 2 of billed charge penalty for failure 23 Eyeglasses and Contacts Coverage is provided for the first pair of eyeglasses or corrective lenses following cataract surgery. 24 Outpatient Physical Therapy Coverage is provided for prescribed services performed by a licensed physical therapist. Note: Your Copayment or Coinsurance for services received from a licensed physical therapist will be no greater than the Copayment or Coinsurance charged for the services provided by a Primary Care Physician for an office visit. Outpatient physical therapy visits will be limited to 20 visits per benefit year. 10 of Covered Eyewear $25 Co-insurance of covered expenses after 25 Outpatient Rehabilitative and Habilitative Services - Other Coverage is provided for Medically Necessary outpatient occupational, speech, cardiac, and pulmonary therapy. Occupational therapy limited to 20 visits per benefit year. Speech Therapy is unlimited when rendered as Physician Home Visits and Office Services or Outpatient Services. Pulmonary therapy is limited to 20 visits per benefit year. Cardiac therapy is limited to 36 visits per benefit year. 26 Inpatient Physical Medicine and Rehabilitation Therapy Services Coverage is provided for Medically Necessary short-term inpatient rehabilitation services when approved by the Plan. Coverage is provided on a semi-private basis. Limited to 60 days per benefit year. Requires Prior Authorization. Co-insurance per admission 27 Mental Health/Substance Use Disorder - Inpatient All inpatient mental health and Substance Abuse/Alcoholism and Chemical Dependency disorder services must be Prior Authorized by calling the Coventry Health Care behavior health line toll free at the number on the back of Your ID Card. Co-insurance per admission 28 Mental Health/Substance Use Disorder - Outpatient Coverage is provided for partial or full day non-residential treatment programs when Prior Authorized by calling the Coventry Health Care behavioral health line at the number on the back of Your ID Card. 29 Mental Health/Substance Use Disorder - Office Visits Includes outpatient mental health and Substance Abuse/Alcoholism and Chemical Dependency services. MOSOBSGPPOCHL814 MO DOI Approved

5 BENEFIT AND SERVICES 30 Transplant Services Services and supplies for transplants are Covered when Participating Coventry Transplant Network Providers are utilized. Requires Prior Authorization. Not Covered Co-insurance per admission Includes unrelated donor searches for bone marrow/ stem cell transplants for a Covered Transplant Procedure, as approved by Us, up to a $30,000 benefit limit. Transportation and lodging limited to $10,000 benefit limit per transplant 31 Accidental Dental Services Covered services limited to $3,000 per benefit year. Prior Authorization is required. Co-insurance per visit 2 of billed charge penalty for failure 32 Autism Services Medically Necessary services to diagnose and treat Autism Spectrum Disorders. Services include: psychiatric and psychological services; habilitative or rehabilitative care; occupational, speech and physical therapy; medications (Covered under Your pharmacy benefit); equipment related to care; and applied behavioral analysis. Prior Authorization is required for some services. See applicable Coverage category for more information Day/visit limitations do not apply to Autism Spectrum Disorder services regardless of the Coverage category. See applicable Coverage category for more information Day/visit limitations do not apply to Autism Spectrum Disorder services regardless of the Coverage category. 33 Hearing Aids for Newborns Hearing Aids provided to a newborn only for initial amplification following a newborn hearing screening (including any necessary rescreening, audio logical assessment and follow-up. Co-insurance per visit **YOU ARE RESPONSIBLE FOR AMOUNTS IN EXCESS OF THE OUT OF NETWORK RATE IN ADDITION TO APPLICABLE COPAYMENT, COINSURANCE AND DEDUCTIBLES. Prescription Drugs - Retail BENEFIT AND SERVICES PRESCRIPTION DRUG BENEFITS Generic: $10 Copay Formulary Tier 1: Formulary Tier 1A: Tier 2: Non-Formulary Tier 3: Specialty Medications Tier 4: Covered when Prior Authorized by the Plan Formulary: $10 Copay $3 Copay $30 Copay $60 Copay $150 Copay Non-Formulary: MOSOBSGPPOCHL814 MO DOI Approved

6 BENEFIT AND SERVICES Specialty Medications Tier 5: Covered when Prior Authorized by the Plan Formulary: Non-Formulary: $300 Copay Prescription Drugs - Mail Order (three-month supply) Generic: $25 Copay Formulary Tier 1: Formulary Tier 1A: Tier 2: Non-Formulary Tier 3: Specialty Medications Tier 4: Covered when Prior Authorized by the Plan $25 Copay $7.50 copay $75 Copay $180 Copay Formulary: Non-Formulary: Specialty Medications Tier 5: Covered when Prior Authorized by the Plan Formulary: Non-Formulary: MOSOBSGPPOCHL814 MO DOI Approved

7 Pediatric Vision Benefit Vision Care Services Exam with Dilation as Necessary Member Cost Out-of-Network Reimbursement Contact Lens Fit and Follow-Up: (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed.) Standard Contact Lens Fit and Follow-Up: Premium Contact Lens Fit and Follow-Up: Frames: Designated available frame at provider location 10 coverage for provider designated frames Standard Lenses (Glass or Plastic): Single Vision Bifocal Trifocal Lenticular Standard Progressive Lens Premium Progressive Lens See attached Fixed Premium Progressive Lens Options: UV Treatment Tint (Fashion & Gradient & Glass-Grey) Standard Plastic Scratch Coating Standard Polycarbonate - Adults Standard Polycarbonate - Kids under 19 Standard Anti-Reflective Coating Polarized Photocromatic / Transitions Plastic Oversized Premium Anti-Reflective Coating Other Add-Ons $40 $45 2 off Retail Price 2 off Retail Price See attached Fixed Premium Anti-Reflective Coating price list 2 off Retail Price Contact Lenses: (Contact lens includes materials only) Extended Wear Disposables Daily Wear / Disposables Medically Necessary / Conventional 10 coverage for provider designated contact lenses Up to 6 mos supply of monthly or 2 week disposable, single vision spherical or toric contact lenses Up to 3 mos supply of daily disposable, single vision spherical contact lenses Paid In Full Laser Vision Correction: Lasik or PRK from U.S. Laser Network Additional Pairs Benefit: Frequency: Examination Lenses or Contact Lenses Frame 15% off Retail Price or 5% off promotional price Members also receive a 4 discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used. Once every Calendar Year Once every Calendar Year Once every Calendar Year

8 Pediatric Dental Care Benefit Schedule of Benefits Pediatric Dental Care Description of Services Type PREVENTIVE & DIAGNOSTIC Coverage Routine Exams/Evaluations I 10 Cleanings I 10 X-rays I 10 Fluoride I 10 Sealants I 10 BASIC Space Maintainer II 5 Fillings II 5 Denture Relines II 5 General Anesthesia General Services II 5 II 5 MAJOR Crowns III 5 Inlays III 5 Onlays III 5 Dentures Bridges III 5 Endodontics III 5 Periodontics III 5 Oral Surgery III 5 Implants III 5 ORTHODONTIA IV 5 Deductible Out-of-Pocket Maximum Deductible & Out-of-Pocket Maximum combined with medical; does not apply to preventive & diagnostic services. MOSOBSGPPOCHL814 MO DOI Approved

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