Independence Blue Cross Plan Summary PPO Core Medical Plan

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1 TO: FROM: SUBJECT: MLH Medical Plan Participants MLH Human Resources Benefits Team Independence Blue Cross Plan Summary PPO Core Medical Plan Attached you will find the Independence Blue Cross (IBC) Plan Summary for the PPO Core Medical Plan effective January 1, The summary provides information about the coverage the plan offers for various common medical plan services. It also includes a summary of services not covered by the plan. This summary represents only a partial listing of the benefits and exclusions of the PPO Core program. Benefits and exclusions may be further defined by IBC medical policies which are available at the web portal. This plan may not cover all of your health care expenses. If you have questions about plan coverage, please contact IBC at ASK-BLUE to speak with a customer service representative. Definitions for Terms Found on the Plan Summary Personal Choice PHO JeffPLUS Personal Choice Personal Choice refers to IBC s Preferred Provider Organization (PPO) medical plan design. The plan gives you the freedom of choice in the providers you choose for your medical care but your cost of care is lower when you use providers who participate in Personal Choice network. A Physician Hospital Organization is a group of physicians and hospitals who agree to contract together with insurance companies. This is the network of PHO providers from MLH, Jefferson and Magee Rehab that is available to employees of the Personal Choice plan. Using these providers will lower your out-of-pocket cost for care. This is the IBC network of physicians and facilities available throughout the Philadelphia region who participate in the Personal Choice plan.

2 Personal Choice Main Line Health PPO PHO Personal Choice, our popular Preferred Provider Organization (PPO), gives you freedom of choice by allowing you to choose your own doctors and hospitals. You can maximize your coverage by accessing your care through Personal Choice's large network of hospitals, doctors and specialists, or by accessing care through preferred providers that participate in the BlueCard PPO program. Of course, with Personal Choice, you have the freedom to select providers who do not participate in the Personal Choice network or BlueCard PPO program. However, if you receive services from out-of-network providers, you will have higher out-of-pocket costs and may have to submit your claim for reimbursement. With Personal Choice... You do not need to enroll with a primary care physician You never need a referral In- Out-of- Benefits JeffPLUS Personal Choice Out-of- * DEDUCTIBLE Individual None $500 $1,000 Family None $1,500 $3,000 BENEFIT PERIOD Calendar Year Calendar Year Calendar Year COINSURANCE 100% unless otherwise noted 80%, after 60%, after OUT-OF-POCKET MAXIMUM *** Individual $3,000 4 $3,000 4 $5,000 Family $5,000 4 $5,000 4 $10,000 LIFETIME MAXIMUM Unlimited Unlimited Unlimited DOCTOR'S OFFICE VISITS Primary Care Services $20 Copayment $40 Copayment, NO 60%, after Specialist Services $25 Copayment $45 Copayment, NO 60%, after PREVENTIVE CARE FOR ADULT AND CHILDREN 100% 100%, NO 60%, after PEDIATRIC IMMUNIZATIONS 100% 100%, NO 60%, NO ROUTINE GYNECOLOGICAL EXAM/PAP 100% 100%, NO 60%, NO age 1 1 routine exam/pap test per calendar year for women of any MAMMOGRAM 100% 100%, NO 60%, NO 4 Combined JeffPLUS/Personal Choice *** In-network out-of-pocket maximum includes, copays and coinsurance. Out-of-network out-of-pocket maximum includes and coinsurance. Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Crossindependent licensees of the Blue Cross and Blue Shield Association. 07/14 - PA JHS-JeffPlus PC PHO - Main Line Health - HCR

3 In- Benefits JeffPLUS Personal Choice OUTPATIENT DIAGNOSTIC SERVICES Routine Radiology MRI/MRA/CAT/PET $15 Copayment (JHS Facility), $20 Copayment (non-jhs $15 Copayment (JHS Facility), $50 Copayment (non-jhs $50 Copayment then 70%, after $75 Copayment then 70%, after Out-of- Out-of- * 60%, after 60%, after Laboratory 100% $20 Copayment per 60%, after occurrence, NO ALLERGY TESTING 100% 80%, after 60%, after ALLERGY EXTRACT/INJECTIONS 100% 80%, after 60%, after MATERNITY First OB Visit $15 Copayment $20 Copayment, NO 60%, after Hospital 100% (JHS facility), $350 after 60%, after 2 CONTRACEPTIVES 100% 100%, NO 60%, after ELECTIVE ABORTION 100% 80%, after 60%, after INPATIENT HOSPITAL SERVICES Facility 100% (JHS facility), $350 after 60%, after 2 Physician/Surgeon 100% 80%, after 60%, after INPATIENT HOSPITAL DAYS EMERGENCY CARE $125 Copayment (Copayment waived if admitted) $125 Copayment, NO (Copayment waived if admitted) URGENT CARE CENTER $70 Copayment, NO $70 Copayment, NO OUTPATIENT SURGERY Voluntary sterilization procedures included; Reversal of sterilization procedures excluded Facility 100% (JHS facility), $100 Copayment per occurrence (non-jhs $300 Copayment per occurrence then 80%, after $125 Copayment, NO (Copayment waived if admitted) ** 60%, after 60%, after Physician/Surgeon 100% 80%, after 60%, after AMBULANCE Emergency 100% 100%, NO 100%, NO Non-Emergency 100% 80%, after 60%, after THERAPY SERVICES Physical, Speech and Occupational $30 Copayment $40 Copayment, NO 60%, after 60 visits per calendar year 1 Cardiac Rehabilitation $30 Copayment $40 Copayment, NO 60%, after 36 visits per calendar year 1 Pulmonary Rehabilitation $30 Copayment $40 Copayment, NO 60%, after 12 visits per calendar year 1 Respiratory Therapy $30 Copayment $40 Copayment, NO 60%, after Orthoptic/Pleoptic $30 Copayment $40 Copayment, NO 60%, after 8 sessions lifetime 1 HEARING EXAM 100% 100%, NO 60%, after HEARING AID REIMBURSEMENT 2 hearing aids every 36 months 1 25% 25%, after 25%, after 2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental illness and substance abuse services 3 Inpatient Copayment waived if readmitted within 10 days of discharge. ** NOTE: for Non-JeffPLUS inpatient hospital admissions through the Emergency Room, the claim is to be processed as a JeffPLUS admission (JeffPLUS admission copay is applied, and coinsurance are waived)

4 In- Out-of- Benefits JeffPLUS Personal Choice Out-of- * CRANIAL PROSTHESIS 50% 50%, after 50%, after per year 1 only covered for members receiving cancer treatment, one RESTORATIVE SERVICES, INCLUDING Not available $40 Copayment, NO 60%, after 30 visits per calendar year 1 CHIROPRACTIC CARE CHEMO / RADIATION / DIALYSIS 100% 80%, after 60%, after OUTPATIENT PRIVATE DUTY NURSING 100% 80%, after 60%, after 360 hours per calendar year 1 SKILLED NURSING FACILITY 100% (JHS facility), $350 60%, after 120 days per calendar year 1 after HOME HEALTH CARE 120 days per calendar year 1 100% 80%, after deductilbe 60%, after HOSPICE 100% (JHS facility), $350 after 60%, after INFUSION THERAPY 100% 80%, after 60%. after MENTAL HEALTH CARE/SERIOUS MENTAL ILLNESS CARE Outpatient Services $25 Copayment $40 Copayment, NO 60%, after Inpatient Facility Services 100% (JHS facility), $350 after SUBSTANCE ABUSE TREATMENT Outpatient/Partial Services $25 Copayment $40 Copayment, NO Inpatient Rehabilitation 100% (JHS facility), $350 Detoxification 100% (JHS facility), $350 after after 60%, after 2 60%, after 60%, after 2 60%, after 2 DURABLE MEDICAL EQUIPMENT Not Available 5 80%, NO 60%, after PROSTHETICS Not Available 80%, NO 60%, after OUTPATIENT DIABETIC EDUCATION 100% 100%, NO Not Covered TRANSPLANT SERVICES 100% 80%, after 60%, after MEDICAL FOODS AND NUTRITIONAL FORMULAS 100% 80%, after 60%, after BLOOD 100% 80%, after 60%, after DIABETIC EQUIPMENT AND SUPPLIES 100% 100%, NO 60%, after 2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental illness and substance abuse services 3 Inpatient Copayment waived if readmitted within 10 days of discharge. What Is Not Covered? Services not medically necessary Services or supplies which are experimental or investigative except routine costs associated with clinical trials Reversal of voluntary sterilization Expenses related to organ donation for non-member recipients Alternative therapies/complementary medicine Dental care, including dental implants, and non-surgical treatment of temporomandibular joint syndrome (TMJ) Music therapy, equestrian therapy and hippotherapy Treatment of sexual dysfunction not related to organic disease except for sexual dysfunction resulting from injury Routine foot care, unless medically necessary or associated with the treatment of diabetes Foot orthotics, except for orthotics and podiatric appliances required for the prevention of complications associated with diabetes Routine physical exams for non-preventive purposes such as insurance or employment applications, college, or premarital examinations Immunizations for travel or employment Service or supplies payable under Workers' Compensation, Motor Vehicle Insurance, or other legislation of similar purpose Cosmetic services/supplies Vision care (except as specified on a group contract) Infertility Self-injectable drugs This summary represents only a partial listing of the benefits and exclusions of the Personal Choice Program described in this summary. If your employer purchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your contract/member handbook carefully for a complete listing of the terms, limitations and exclusions of the program. If you need more information, please call (outside Philadelphia) or (if calling within the Philadelphia area).

5 Certain services require preapproval/precertification by the health plan prior to being performed. To obtain a list of services that require authorization, please log on to or call the phone number that is listed on the back of your identification card.

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