National PPO PPO Schedule of Payments (Maryland Small Group)

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1 PPO Schedule of Payments (Maryland Small Group) National PPO 1000 The benefits outlined in this Schedule are in addition to the benefits offered under Coventry Health & Life Insurance Company Small Employer Health Plan and Standard Package Cost Sharing for Maryland Small Employers. The benefits described herein are chosen at the Small Employer s option for an additional Premium to provide lower cost sharing for Members. Benefit Year Individual Family Amounts for Participating and s services are combined in calculating when the is met. Benefit Year Out-of-Pocket Maximum Includes Member paid s, Coinsurance, Emergency Room Copayment and Urgent Care Center Copayments. Individual Family Amounts for Participating and s services are combined in calculating when the Out-of- Pocket Maximum is met. $1,000 $2,000 $2,500 $5,000 $2,000 $4,000 $4,500 $9,000 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 (If applies, no will apply for Mammography) 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) $0 Copayment $0 Copayment $20 Copayment $40 Copayment 20% Coinsurance CHL(MDSG) of 5 CNN 1000

2 Urgent and Emergency Care Services At an Urgent Care Center At a Hospital Emergency Room (waived if admitted) 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)* $20 Copayment or 20% after per trip after $20 Copayment $0 Copayment $40 Copayment after $40 Copayment after $0 Copayment after $0 Copayment after $40 Copayment per service after Coinsurance, whichever is less, after CHL(MDSG) of 5 CNN 1000

3 Short-Term Therapies* Physical Speech Occupational Respiratory Cardiac Rehabilitation. (Short-term Therapies are covered for up to 30 visits for each therapy per condition per Benefit Year) 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 Outpatient Family Planning Services Elective Sterilization, Male or Female Inpatient Elective Sterilization Infertility Services* (after confirmed diagnosis) 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* Prosthetic Devices and Durable Medical Equipment (DME)* Authorized certain prosthetic devices and durable medical equipment Hearing Aids for Minor Children (Limited to $1400 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 condition per Benefit Year) 50% Coinsurance after $40 Copayment per day after $40 Copayment after $40 Copayment after 40% Coinsurance, or $40 Copayment, whichever is greater, after 40% Coinsurance after 50% Coinsurance after Podiatry Services (Limited to 10 visits per Benefit Year) $40 Copayment CHL(MDSG) of 5 CNN 1000

4 Mental Illness, Emotional Disorders, Drug and Alcohol Abuse Services* Inpatient Hospital Care Residential Crisis Services Partial Hospitalization Outpatient Visits Medication Management Visit PCP Specialist $0 Copayment per day after $20 Copayment $40 Copayment *These benefits require prior authorization 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 applicable Copayment will not exceed 75% of the cost of any prescription drug. A Maintenance Drug is a drug that is needed for 6 months or more to treat a chronic condition and is usually dispensed in a single dispensing. Coverage for a 90 day supply of a Maintenance Drug in a single dispensing is not available for the first prescription of a Maintenance Drug or a change in a prescription of a Maintenance Drug. If a Provider prescribes a brand name drug for which a generic is available, and the Member selects the brand name drug rather than the generic, the member pays the Copayment plus the difference between the price of the generic and the brand name drug. A separate pharmacy deductible listed on this Schedule of Payments applies for prescription drug coverage and each individual within a family unit must meet the separate pharmacy deductible before prescriptions are covered at Participating Provider retail and mail order pharmacies. : The must be met before the services listed on this Schedule of Payments will be covered. Each individual within a family unit can access coverage from the plan once his or her individual has been met. CHL(MDSG) of 5 CNN 1000

5 Benefits are administered on a Benefit year basis. For s, Eligible Charges are based on the lesser of the provider's billed charges or our Out-of-Network Rate, which is defined in your Certificate of Insurance. 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 carefully regarding when out-of-network services may be included in your coverage. Out-of-Network Rate: The maximum amount covered by Us for approved out-of-network services. This rate will be derived from either a Medicare based fee schedule or a percent of billed charges as determined by Us, based on the following: Non-Participating Physicians Fees. The Out-of-Network Rate is equivalent to a percentage of the 2002 Medicare RBRVS fee schedule for physician charges. The fee schedule shall be based upon the geographic area in which the Health Plan offers coverage and not upon the location of the provider. If the 2002 Medicare RBRVS fee schedule does not contain a reimbursement level for a specific code, St. Anthony s RBRVS will be used in its place. For CPT codes developed after 2002 Medicare RBRVS fee schedule, the Health Plan shall assign a reimbursement valuation on an annual basis consistent with the percentage methodology described. If none of the above procedures yields a corresponding RBRVS rate for a particular service, the Health Plan shall pay 50% of billed charges. Non-Participating Facility Fees. The Out-of-Network Rate is equivalent to a percentage of the Medicare reimbursement schedule for facility charges. Inpatient rates shall be set according to then-current DRG s ( Diagnosis Related Group ). Outpatient services will be paid at either a percentage of the then-current Medicare reimbursement schedule for ASC s ( Ambulatory Surgical Centers ) or at 60% of billed charges. 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(MDSG) of 5 CNN 1000

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