SERVICES IN-NETWORK COVERAGE OUT-OF-NETWORK COVERAGE

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1 COVENTRY HEALTH AND LIFE INSURANCE COMPANY 3838 N. Causeway Blvd. Suite 3350 Metairie, LA SCHEDULE OF BENEFITS BENEFITS AND PRIOR AUTHORIZATION REQUIREMENTS ARE SET FORTH IN ARTICLES IV AND V OF THE GROUP MASTER AGREEMENT (GMA). THE AMOUNT OF PROVIDED UNDER THE GROUP MASTER CONTRACT IS SET FORTH IN THIS SCHEDULE OF BENEFITS. Any Benefits provided by a Participating Health Care Provider shall be covered in accordance with the Group Master Contract and at the In-Network Coverage Level Coinsurance amount. Benefits provided by a non-participating Health Care Provider shall be covered in accordance with the Group Master Contract at the Out-of-Network amount unless coverage is specifically excluded at the Out-of-Network Care Level or the Schedule of Benefits states otherwise. EVEN IF A MEMBER HAS PAID THE OUT-OF-POCKET MAXIMUM, A MEMBER IS STILL REQUIRED TO PAY AMOUNTS IN EXCESS OF ELIGIBLE CHARGES (I.E., NON-ELIGIBLE CHARGES). YOUR SHARE OF THE PAYMENT FOR HEALTH CARE SERVICES MAY BE BASED ON THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER. UNDER CERTAIN CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW YOUR PROVIDER TO BILL YOU FOR AMOUNTS UP TO THE PROVIDER S REGULAR BILLED CHARGES. PAYMENT OF COPAYMENT (S) IS IN ADDITION TO, AND NOT INSTEAD OF, PAYMENT OF AMOUNTS THE MEMBER IS REQUIRED TO PAY IN EXCESS OF COINSURANCE. SERVICES IN -NETWORK OUT-OF-NETWORK COINSURANCE UNLESS DIFFERENT AMOUNT OF COINSURANCE IS EXPRESSLY STATED BELOW: DEDUCTIBLE: TO ALL ELIGIBLE CHARGES INCURRED BY A MEMBER (SINGLE) OR FAMILY DURING THE DEDUCTIBLE ACCUMULATION PERIOD. DEDUCTIBLE ACCUMULATION PERIOD: 30% OF ELIGIBLE CHARGES AFTER APPLICABLE DEDUCTIBLES, AND COPAYMENTS ARE APPLIED $1,000 FAMILY DEDUCTIBLE FOR THE SAME DEDUCTIBLE ACCUMULATION PERIOD IS EQUAL TO 2 TIMES THE 50% OF ELIGIBLE CHARGES AFTER APPLICABLE DEDUCTIBLES, AND COPAYMENTS ARE APPLIED $2,000 FAMILY DEDUCTIBLE FOR THE SAME DEDUCTIBLE ACCUMULATION PERIOD IS EQUAL TO 2 TIMES THE 1 #15047

2 SERVICES IN-NETWORK OUT-OF-NETWORK OUT-OF-POCKET MAXIMUM: SINGLE $5,000 FAMILY $10,000 SINGLE $10,000 FAMILY $20,000 OUT-OF-POCKET MAXIMUMS ARE CALCULATED BY ADDING TOGETHER THE PORTION OF ELIGIBLE CHARGES PAID BY A MEMBER OR FAMILY DURING THE OUT-OF-POCKET ACCUMULATION PERIOD,OTHER THAN ELIGIBLE CHARGES FOR MENTAL HEALTH SERVICES AND SUBSTANCE ABUSE, AND PRESCRIPTION DRUG BENEFITS, COPAYMENTS, FINANCIAL PENALTIES AND ELIGIBLE CHARGES IN EXCESS OF BENEFIT MAXIMUMS. DEDUCTIBLES APPLY TO THE OUT OF POCKET MAXIMUM. OUT-OF-POCKET MAXIMUMS FOR THE IN- NETWORK AND THE OUT- OF-NETWORK LEVEL ARE NOT COMBINED. OUT OF POCKET MAXIMUM ACCUMULATION PERIOD MAXIMUM LIFETIME BENEFITS UNLIMITED UNLIMITED ALLERGY SERVICES ALLERGY TESTING AMBULANCE SERVICE BLOOD ADMINISTRATION BLOOD AND BLOOD PRODUCTS ARE NOT COVERED BONE MASS MEASUREMENT PERFORMED IN PHYSICIAN S OFFICE CANCER CLINICAL TRIALS PHYSICIANS OFFICE CARE CARE 2

3 SERVICES IN-NETWORK OUT-OF-NETWORK CANCER DRUG PHYSICIANS ADMINISTRATION HOME HEALTH ADMINISTRATION CANCER SCREENING MAMMOGRAM CHIROPRACTIC SERVICES ALL CHIROPRACTIC SERVICES PROVIDED BY A CHIROPRACTOR WITHIN THE SCOPE OF HIS/HER LICENSE AND COVERED BY OTHER SECTIONS OF THIS SCHEDULE OF BENEFITS CLEFT LIP AND CLEFT PALATE TREATMENT AND CORRECTION $25 COPAYMENT COVERED ON THE SAME TERMS AND CONDITIONS AS OTHER ILLNESSES AND INJURIES SEE APPLICABLE BENEFIT DESCRIPTION, LIMITATIONS, AND COST SHARING PROVISIONS CORRECTIVE LENSES DENTAL ANESTHESIA DIABETES MANAGEMENT AND TREATMENT 1 ST PAIR ONLY FOLLOWING CATARACT SURGERY DURABLE MEDICAL EQUIPMENT, PROSTHETIC AND ORTHOTIC DEVICES AND SERVICES REQUIRES PRE-AUTHORIZATION EMERGENCY MEDICAL SERVICES EMERGENCY ROOM COPAYMENT WAIVED IF ADMITTED PHYSICIANS OFFICE/ URGENT CARE WAIVED IF ADMITTED $200 COPAYMENT $200 COPAYMENT $75 COPAYMENT $75 COPAYMENT 3

4 SERVICES IN-NETWORK OUT-OF-NETWORK FAMILY PLANNING INSERTION & REMOVAL OF INTRAUTERINE DEVICES/DIAPHRAGM TUBAL LIGATION AND VASECTOMY INFERTILITY DIAGNOSTIC TESTING $1,500 BENEFIT MAXIMUM FOR IN-NETWORK AND OUT-OF-NETWORK COMBINED GYNECOLOGICAL EXAMINATION ROUTINE VISITS LIMITED TO 2 VISITS PER YEAR HEALTH EDUCATION SERVICES HEARING AIDS FOR CHILDREN UNDER 18 YEARS OF AGE MAXIMUM $1, PER EAR BENEFIT AVAILABLE ONCE PER EAR EVERY 36 MONTHS HEARING IMPAIRED INTERPERTER EXPENSES HOME HEALTH CARE PHYSICIAN HOME VISITS HOSPICE CARE HOSPITAL CARE INJECTABLE DRUGS IMMUNIZATIONS THERAPEUTIC INJECTIONS 4

5 SERVICES IN-NETWORK OUT-OF-NETWORK LOW PROTEIN FOOD PRODUCTS LIMITED TO $200 PER MONTH FOR COMBINED IN AND OUT-OF-NETWORK SERVICES MATERNITY CARE OFFICE VISTS AND RELATED SERVICES NOTIFICATION REQUIRED WHEN PREGNANCY CONFIRMED FIRST PHYSICIAN OFFICE VISIT IF MEMBER CHANGES PHYSICIAN BEFORE DELIVERY, REQUIRED TO PAY ADDITIONAL $50 COPAYMENT FOR FIRST OFFICE VISIT WITH NEW PHYSICIAN MENTAL ILLNESS COVERED ON THE SAME TERMS AND CONDITIONS AS OTHER ILLNESSES AND INJURIES SEE APPLICABLE BENEFIT DESCRIPTION, LIMITATIONS, AND COST SHARING PROVISIONS AUTISM REQUIRES PRE-AUTHORIZATION APPLIES TO CHILDREN UNDER 17 YEARS OF AGE IN EMPLOYER GROUPS OF OVER 50 EMPLOYEES ORAL SURGERY PHYSICIAN S OFFICE AUTISM SERVICE PROVIDER, CERTIFIED AS A BEHAVIOR ANALYST PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY 5 PHYSICIAN S OFFICE AUTISM SERVICE PROVIDER, CERTIFIED AS A BEHAVIOR ANALYST PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY

6 SERVICES IN-NETWORK OUT-OF-NETWORK SURGERY PHYSICIAN SERVICES $25 COPAYMENT PRIMARY CARE OFFICE VISIT SPECIALTY PHYSICIAN PROFESSIONAL SERVICES PERIODIC HEALTH EXAMS AND HEALTH ASSESSMENTS RECONSTRUCTIVE BREAST SURGERY RECONSTRUCTIVE SURGERY SECOND OPINION REQUIRES PRE-AUTHORIZATION SPEECH, PHYSICAL, OCCUPATIONAL, PULMONARY AND CARDIAC REHABILITATION THERAPY LIMITED TO 180 DAYS FROM ONSET FOR IN-NETWORK & OUT-OF-NETWORK COMBINED SKILLED NURSING FACILITY SUBSTANCE ABUSE 30 DAY MAXIMUM FOR IN-NETWORK AND OUT-OF-NETWORK COMBINED COVERED ON THE SAME TERMS AND CONDITIONS AS OTHER ILLNESSES AND INJURIES SEE APPLICABLE BENEFIT DESCRIPTION, LIMITATIONS, AND COST SHARING PROVISIONS 6

7 SERVICES IN-NETWORK OUT-OF-NETWORK TRANSPLANTS SEE GMA FOR TRAVEL & TESTING INFORMATION X-RAY, LABORATORIES AND DIAGNOSTIC TESTS LAB CT, MRI, MRA, PET SCANS ALL OTHER X-RAYS 7

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