PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA

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1 PPO Schedule of Payments (Maryland Large Group) Qualified High Health Plan National QA Benefit Year Individual Family (Amounts for Participating and s services are separated in calculating when the is met.) Benefit Year Out-of-Pocket Maximum (, Coinsurance and Copayment amounts are combined to determine when the maximums are met.) Individual Family (Amounts for Participating and s services are separated in calculating when the Out-of- Pocket Maximum is met.) $2,000 $4,000 $4,500 $9,000 $4,000 $8,000 $7,000 $14,000 Lifetime Maximum Physician Services COVERED SERVICES ( applies as indicated) Unlimited Child Well Care and Immunizations Routine Preventive Services-Annual Adult Physical Gynecological Exam & PAP Test PCP Office Visits for Illness or Injury Allergy Treatments & Testing Services Specialist Office Visits for Illness or Injury Allergy Treatments & Testing Services (Physician Services are limited to one Copayment per member per provider date of service) Urgent and Emergency Care Services At a Medical Aid Unit or Urgent Care Center At a Hospital Emergency Room (Copayment will be waived, if admitted) $0 Copayment per visit $0 Copayment per visit CHL(MDLG) of 5 CNN QA

2 Ambulance (Coventry Health and Life Insurance Company must be notified within 48 hours of initial treatment in an emergency) Inpatient Hospital Care* Semi-Private Room or Private Room when Medically Necessary Medications & Drugs Nursing Care Intensive / Coronary Care Radiation Therapy Administration of Blood Transplant Services X-rays and Laboratory Professional Services Maternity and Newborn Services Prenatal & Postnatal Physician Services 1st visit Subsequent visits (Includes Home Health Care for post-partum visits- No Copayment or Coinsurance will apply for Home Health Care post-partum visits) Inpatient Hospital Care* Outpatient Surgery Free-Standing Surgi-Center* Outpatient Department of a Hospital* Outpatient Laboratory / Outpatient Diagnostic Services X-ray and Ultrasound Laboratory Specialized Radiology (including CAT, MRI, MRA, PET)* Short-Term Therapies* Physical Speech Occupational Respiratory Cardiac Rehabilitation. (Short-term Therapies are covered from their original onset for up to 20 visits) Habilitative Services* For children up to and including the age of 19 years for services including occupational therapy, physical therapy, and speech therapy. Voluntary Family Planning Family Planning Services Elective Sterilization, Male or Female $250 Copayment per admission after $250 Copayment per admission after 5 5 CHL(MDLG) of 5 CNN QA

3 Infertility Services* (Coverage only for testing to diagnose infertility) In Vitro Fertilization* (Limit of 3 attempts per live birth and $100,000 per lifetime) Skilled Nursing Facility* Facility, supplies and equipment authorized in lieu of acute care hospitalization within the service area for up to 100 days per Benefit Year. Home Health Care* Authorized in lieu of acute care hospitalization within the service area. Hospice* Authorized in lieu of acute care hospitalization within the service area. Prosthetic Devices and Durable Medical Equipment (DME)* Authorized certain prosthetic devices and durable medical equipment, including the components of and repairs to those devices. Hearing Aids for Minor Children (Limited to $1,400 per hearing aid per ear every 36 months) Hair Prosthesis- resulting from Chemotherapy or radiation treatment for cancer (Limited to one 1 hair prosthesis not to exceed $350) Chiropractic Services (Limit of 20 visits per Benefit Year) Podiatry Services (Limited to 10 visits per Benefit Year) Mental Illness, Emotional Disorders, Drug and Alcohol Abuse Services* Inpatient Hospital Care Residential Crisis Services Partial Hospitalization Outpatient Visits Medication Management Visit (The copayment for methadone maintenance treatment will never exceed 50% of the daily cost for such treatment.) 5 $250 Copayment per admission after $250 Copayment per admission after 5 CHL(MDLG) of 5 CNN QA

4 Prescription Drugs** Benefits apply to Prescription Drugs received at retail and mail order pharmacies. Copayment or coinsurance requirement for a covered Prescription Drug or device will not exceed the retail price of the prescription drug or device. Tier 1 Formulary Drugs Tier 2 Formulary Drugs Tier 3 Non-Preferred Drugs Self Administered Injectable Drugs (other than insulin) $0 Copayment per prescription after $0 Copayment for 90-day supply after $25 Copayment per prescription after $62.50 Copayment for 90-day supply after $50 Copayment per prescription after $150 Copayment for 90-day supply after 50% of allowable charge, not to exceed $75 after $0 Copayment per prescription after $0 Copayment for 90-day supply after $25 Copayment per prescription after $62.50 Copayment for 90-day supply after $50 Copayment per prescription after $150 Copayment for 90-day supply after 50% of allowable charge, not to exceed $75 after *These benefits require pre-certification by Coventry Health and Life Insurance Company or payment is denied. Refer to your Certificate of Insurance for more information. Payments the Member makes due to a denial of benefits are not applied to the Out-of-Pocket Maximum. **Copayments are per Prescription Order or Refill. Self-Administered Injectable Drugs are not available by mail order. Prescription Drugs that require authorization are identified in the Formulary with PA next to the name of the drug. The must be met before the services listed on this Schedule of Payments will be covered. The individual applies only when the member has employee only coverage. For policies that include the member and one or more dependent, any number of family members may help to meet the family deductible amount. Benefits are administered on a Benefit year basis. In addition to your Copayment or Coinsurance, you are responsible for paying s the difference between our Out-of-Network Rate and their actual charge for non-emergency services. Your Out-of-Pocket costs for non-emergency care from s may be substantial. This plan is underwritten by Coventry Health and Life Insurance Company. Refer to your Certificate of Insurance, applicable Riders and this Schedule of Payments to determine exact terms, conditions and scope of coverage, including all exclusions and limitations and defined terms. PLEASE NOTE THAT IF YOU RECEIVE SERVICES FROM AN OUT-OF-NETWORK PROVIDER, YOUR COINSURANCE AMOUNT WILL BE APPLIED TO THE OUT-OF-NETWORK RATE TO DETERMINE HOW MUCH WE PAY FOR COVERED SERVICES PROVIDED BY THE OUT-OF-NETWORK PROVIDER. Based on your benefit plan, You may have limited coverage for out-of-network services. Please review your Certificate of Insurance (COI) carefully regarding when outof-network services may be included in your coverage. Out-of-Network Rate: The Out-of-Network Rate is the rate we pay for claims for services rendered by a non-. We will pay the claims as follows: CHL(MDLG) of 5 CNN QA

5 ñ "claims submitted by a hospital will be paid at the rate approved by the Health Services Cost Review Commission; ñ "claims submitted by a trauma physician for trauma care rendered to a trauma patient in a trauma center will be paid at the greater of: ñ "140% of the rate paid by the Medicare program, as published by the Centers for Medicare and Medicaid Services, for the same covered service to a similarly licensed provider, or ñ "the rate as of January 1, 2001 that We paid in the same geographic area, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider; and ñ "claims submitted by any other health care provider will be paid at the greater of: ñ "125% of the rate We pay in the same geographic area, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider who is a, or ñ "the rate We paid as of January 1, 2000, in the same geographic area, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider who is not a. This is not a contract or a definitive statement of benefits. It is intended solely to provide you with an overview of the proposed Coventry benefits. Complete details of benefits, terms and exclusions are governed by your Coventry Certificate of Insurance (COI). The Coventry COI may not cover all your health care expenses. Read your COI carefully to determine which health care services are covered. If you have questions call us toll free at CHL(MDLG) of 5 CNN QA

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