Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO Effective 1/1/2016

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1 Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO Effective 1/1/2016 This Schedule of Benefits summarizes your obligation towards the cost of certain covered services. Refer to your Plan Document for a detailed description of covered services and limitations or exclusions. *The Participant will be responsible for 100% of amounts above the Out-of-Network Rate. All services must be medically necessary as a condition of coverage and not otherwise limited or excluded. BENEFITS AND SERVICES 1. Annual Deductible MEDICARE ASSIGNED CLAIMS MEMBER RESPONSIBILITY MEDICARE NON-ASSIGNED CLAIMS MEDICARE NON-COVERED CLAIMS FOR SERVICES THAT THE PLAN COVERS IN-NETWORK OUT-OF-NETWORK Total amount a plan Participant is required to pay each calendar year before applicable coinsurance is applied to covered services. The Annual Deductible need only be met once per plan Participant per calendar year. Individual Medical $450 Private Duty Nursing $50 Individual Medical $450 Private Duty Nursing $50 Individual Medical $ Annual Out-of-Pocket Maximum (per Individual) The annual Out-of-Pocket Maximum need only be met once per Plan Participant per calendar year. $0 $0 $1,600 $2,425 The following applies to the Out-of- Pocket Maximum: Medical Coinsurance for Covered services and supplies Medical Deductible Medical Copayments The following does not apply to the Out-of-Pocket Maximum: Pharmacy Deductible Pharmacy Copayments Pharmacy Coinsurance Costs above the Out-of-Network Rate Non-Covered services and supplies Utilization review penalties Refer to the Plan Document for the complete definition of Out-of-Pocket Maximum. deductible. On Medicare non-assigned claims, members have Effective 1/1/

2 3. Maximum Lifetime Benefit Combined total of all Covered Benefit Unlimited Unlimited Unlimited Unlimited 4. Allergy Injections 1 2 Rate * 5. Cancer screenings Coverage includes non-preventive cancer screenings. Cancer screenings not coded as preventive shall include the screenings and office visits related to the screening Chiropractic Services Coverage is provided for manipulation and spinal X-ray services. Office visit not covered. 1 Limited to 30 manual manipulation of the spine treatments per calendar year and 1 spinal X-ray per calendar year after deductible 2 Limited to 30 manual manipulation of the spine treatments per calendar year and 1 spinal X-ray per calendar year 7. Contraceptives Certain services may be Covered under the Preventative Care Benefit. Refer to the Preventative Care section of Article 5 of the Summary Plan Document. up to age 55 years. After age 55 years, deductible, copays and coinsurance apply. Refer to the Birth Control section of Article 5 of the Summary Plan Document. deductible. On Medicare non-assigned claims, members have Effective 1/1/

3 8. Durable Medical Equipment and Diabetic Supplies Covered diabetic supplies include glucose monitors, test strips and lancets Emergency Ambulance Services Coverage is provided for Emergencies as defined in the Plan Document Emergency Care Services Coverage is provided for worldwide emergency health services as defined in the Plan Document. Copayment waived if accidental injury or patient is admitted. Participants may have no additional $75 Copayment then 1 If deemed Emergency Care: $75 Copayment then 10% Coinsurance of negotiated rate or billed charges after Deductible* If not deemed Emergency Care: $75 Copayment then 20% Coinsurance Deductible* 11. First Three Pints of Blood 1 2 deductible. On Medicare non-assigned claims, members have Effective 1/1/

4 12. Hearing Aids and Screenings for Dependent children with developmental delays up to 26 years of age (including Cochlear Implants and Bone Anchored Hearing Aids) 1 Limited to 1 hearing aid per ear every 24 months. Limited to 1 diagnostic hearing screening and/or audiogram every 12 months. 13. Home Health Care and Hospice Immunizations Coverage is provided in accordance with the recommended schedules in Appendix B of Article 5. The Plan will Cover the Zoster (shingles) vaccine and administration for Participants fifty (50) years of age and older. after the Medicare of eligible expenses Shingles vaccine and administration is only Covered when received from a Participating Pharmacy. 15. Inpatient Hospital Services Unlimited coverage is provided for medically necessary physician and surgeon services, semi-private accommodations (unless a private room is the only room available or is required for medical reasons), operating rooms and related facilities, intensive and coronary care units, laboratory, x-rays, radiology services and procedures, medications and biologicals, anesthesia, special duty nursing as prescribed, short-term rehabilitation services, nursing care, meals and special diets. 1 2 deductible. On Medicare non-assigned claims, members have Effective 1/1/

5 16. Maternity Care, Inpatient Hospital Coverage for subscriber and Dependent. Covered services include all physician services for mother and newborn(s), delivery, newborn nursery services and semi-private accommodations (unless a private room is the only room available or is required for medical reasons). 1 2 Coverage for newborns limited to 48 hours for a vaginal delivery or 96 hours for a cesarean section, unless eligible to enroll in Plan as a dependent. 17. Maternity Care Office Visits Coverage for subscriber and Dependent. Covered services include pre-natal and post-natal care, examinations, tests and educational services. (Infertility testing, office visit treatments and surgery are not covered.) Mental Health/Substance Abuse - Inpatient Mental Health/Substance Abuse - Outpatient Nutritional Counseling Coverage is provided for nutritional counseling as referenced in Nutritional Counseling section of the Summary Plan Document. deductible. On Medicare non-assigned claims, members have Effective 1/1/ $0 Copayment or 0% Coinsurance of eligible expenses

6 21. Office Visits Non-preventive care including diagnosis, consultation and telemedicine. 1 2 Preventive care office visits not covered 22. Orthotic Appliances and Prosthetic Devices Outpatient Services and Diagnostic Procedures and Tests Coverage includes diagnostic procedures and tests, including but not limited to lab, radiology, and mammography. Certain procedures and tests are considered surgery, including but not limited to colonoscopy and endoscopy. Refer to the Outpatient Surgery section. 1 2 services not Covered 24. Outpatient Surgery Benefits are provided for covered services rendered at an outpatient hospital or free standing surgery center. 1 2 deductible. On Medicare non-assigned claims, members have Effective 1/1/

7 25. Services include immunizations as outlined in Article 5 of the Plan document and any service, procedure or office visit coded as preventive, including but not limited to preventive cancer screenings, routine health assessments, well-child care, and child health supervision services. If covered by Medicare, of eligible expenses of eligible expenses This is applied to routine or preventive services excluding dental, hearing and vision services. Cancer screenings not coded as preventive may be applied to deductible and coinsurance. Refer to the Cancer Screenings section. Refer to the Office Visits section. Shingles vaccine and administration is covered under Part D. 26. Prosthetics Devices and Orthotic Appliances Refer to the Orthotic Appliances and Prosthetic Devices section. 27. Skilled Nursing Facility Coverage is provided in lieu of an inpatient hospital admission. Coverage is provided for a semiprivate accommodations (unless a private room is the only room available or is required for medical reasons). 1 2 deductible. On Medicare non-assigned claims, members have Effective 1/1/

8 28. Therapy Rehabilitation Services and Supplies Coverage is provided for Medically Necessary Therapy Services as defied in Article Limited to a combined total of 60 physical, occupational, and speech therapy visits per calendar year for both in-network and out-of-network and is subject to applicable deductibles(s) and Coinsurance 2 Limited to a combined total of 60 physical, occupational, and speech therapy visits per calendar year for both innetwork and outof-network and is subject to applicable deductibles(s) and Coinsurance 29. Transplant Services Prior Authorization required. Contact the Claims Administrator s Transplant Case Manager for Transplant Benefits and Covered services. During the Case Rate Participant is responsible for Coinsurance equal to 0% of the case rate that is in effect at the time of service as agreed to by the Claims Administrator and the closest Designated Transplant Network Facility. Deductible does not apply. During the Case Rate Participant is responsible for: Coinsurance equal to 20% of the case rate that is in effect at the time of service as agreed to by the Claims Administrator and the closest Designated Transplant Network Facility After the case rate Participant is responsible for the Deductible then a Coinsurance equal to 10% of the approved amount for the services received. plus the difference between the case rate and the Non- Participating Provider payment schedule that is in effect at the time of service. Deductible does not apply. After the case rate Participant is responsible for the Deductible then a Coinsurance equal to 20% of the approved amount for the services received. deductible. On Medicare non-assigned claims, members have Effective 1/1/

9 30. Urgent Care Services Urgent Care Services (as deemed Urgent Care by the Claims Administrator) that are received at participating alternate facilities both in and out of the service area are Covered. Participants may have no additional 1 If deemed Urgent Care: 1 of negotiated rate or billed charges If not deemed Urgent Care: 2 of the Out-of- Network Rate * 31. Vision Services Services Refer to Vision Services section of Article 5 for Covered services. of Medicare allowed amount after deductible Participants may have no additional Payment 1 2 of the Out-of- Network Rate * deductible. On Medicare non-assigned claims, members have Effective 1/1/

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