Your Out-of-Pocket Type of Service

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1 Calendar Year Deductible (CYD) 1 $5,000 single/ 2x family Out-of-Pocket Maximum - Deductibles and copays all accrue towards the out-of-pocket $6,000 single/ 2x family maximum. With respect to family plans, an individual is only subject to the individual out-ofpocket maximum amount. When two family members have each satisfied their individual out-ofpocket maximum amount, then the family out-of-pocket maximum amount is met. 2 Physician Office Visits Telemedicine services $30 copay Primary care practitioner (PCP) 3 Specialist office visit - will require prior authorization 4 PCP and specialist copay applies to all services in the practitioner s office unless the service is also listed on this summary of benefits with an additional copay. Alternative Medicine - Homeopathy, acupuncture and integrated medicine. $1,500 maximum per calendar year. Ambulance Services - Medically necessary only. Air ambulance Ground ambulance $200 copay per trip $200 copay per trip Durable Medical Equipment 5 Rental Items approved for purchase Emergency Care - Includes surgeon and physician costs. Emergency room - The copay is waived when the member is admitted as an inpatient directly from the emergency room. If you receive services from an out-of-network provider, the physician will be fully reimbursed at the usual and customary rate. Urgent care - In and 0ut-of-area urgent care services are covered for medically necessary covered services. Members should call Prominence Health Plan Member Services for assistance prior to obtaining out-of-area urgent care services. Health and Wellness Services Online Wellness Assessment - OWA Link: prominencehealthplan.com Telephonic health coaching - Six sessions per condition per calendar year (diabetes management, tobacco cessation and weight management) Hearing Aids - Limited to one every three years. Home Healthcare Hospice Care Hospice care Respite inpatient - Limited to 10 per 6 months. Respite outpatient - Limited to 10 visits per year. Bereavement services - Limited to 5 visits per year. 6XHEXS50T $50 copay per item $400 copay per visit Page 1

2 Hospital/Outpatient/Ambulatory Services 6 - *Includes surgeon, facility and anesthesia charges Inpatient* Outpatient surgery* Observation* - No additional copay if transferred from outpatient surgery. Inpatient skilled nursing - Limited to 100 days per calendar year. Acute rehabilitation Infusion Therapy* Performed and billed by a physician s office or free-standing, outpatient facility Performed and billed by a hospital outpatient facility * Specialty drugs incur 20% copay Kidney Dialysis Services - Covered to the extent not covered by Medicare. Laboratory and Pathology Services Laboratory Pathology Mastectomy Reconstructive Services Inpatient surgery Outpatient surgery Maternity Physician: prenatal care and delivery Delivery room and well-baby hospital care Ancillary maternity charges - including but not limited to fetal non-stress tests and amniocentesis Medical Nutrition Therapy Counseling - Limited to 25 visits per calendar year. Mental Health Services Severe Mental Illness Inpatient Day treatment program Outpatient Outpatient office visit General Mental Health Outpatient office visit Alcohol and Drug Abuse Services Inpatient withdrawal Inpatient rehabilitation Outpatient rehabilitation/day treatment Outpatient office visit $200 copay per delivery

3 Nutritional Supplements - Enteral Therapy and Parenteral Nutrition. Maximum 120 days supply for special food products. Organ Transplants Orthotics - Foot orthotics limited to one pair per year Ostomy Supplies Preventive Services 7 Colorectal cancer screening, colonoscopy, sigmoidoscopy, or fecal occult blood test Mammograms - baseline and annual Pap and pelvic exams Periodic health assessments for hearing and vision for ages 19 and under BRCA genetic counseling and testing services Prenatal well visits Prostate screenings Well baby and child visits, immunizations/vaccinations for children through age 17 Preventive sterilization Prosthetic Prosthetic devices Dental/oral orthotic appliances, TMJ and/or sleep apnea - Limited to one appliance per member per calendar year. Radiation Oncology Therapy Specialist office visit Hospital outpatient therapy facility fee Radiology and Diagnostic Services 8 Routine X-ray and Routine Diagnostic Tests Performed and billed by a free-standing, outpatient facility Performed in and billed by a hospital outpatient facility CT SCAN and MRI Performed and billed by a free-standing, outpatient facility Performed and billed by a hospital outpatient facility Radiology and Diagnostic Services 8 (continued) Complex Diagnostic Testing Performed and billed by ar free-standing, outpatient facility Performed and billed by a hospital outpatient facility Spinal Manipulation Temporomandibular Joint Dysfunction TMJ surgery - inpatient hospital TMJ non-surgical outpatient office visit $20 copay per 30 day supply $50 copay per item $50 copay $600 copay $600 copay Page 3

4 Therapies Physical, occupational and speech Habilitative Rehabilitative Autism spectrum disorders Vision - Pediatric 9 - Coverage up to age 19 Eye exam - Limited to one routine eye exam per child per year. Low-vision exam - Limited to one routine eye exam per child per year. Glasses - Limited to one pair of basic frames and lenses. Post-cataract services - Limited to one pair of basic frames and lenses. Dental - Pediatric - This plan excludes coverage for Pediatric Dental Services. You are required to purchase and maintain Pediatric Dental Coverage through a standalone dental plan offered through Healthcare.gov Texas Marketplace. Prescription Coverage In-network Pharmacy FDA-approved preventive medications, including female oral contraceptives Generic Preferred brand Non-preferred brand Specialty drugs $0 copay $15 copay $75 copay $150 copay CYD/20% copay PharmacyPlus PharmacyPlus generic $10 copay PharmacyPlus brand $70 copay Members have the option to fill certain available prescriptions at PharmacyPlus locations for a discounted copay amount. For a complete list of PharmacyPlus locations, please refer to the provider directory. Provider directories can be found online at. Diabetic supplies obtainable from a pharmacy (including: needles, syringes, test strips, lancets and alcohol swabs) available at retail or mail order. This health plan is not a Medicare Supplement policy. The Evidence of Coverage (EOC) sets forth in detail the rights and obligations of both you and the Plan. It is important you review the EOC once you are enrolled. This disclosure statement provides only a brief description of some important features and limitations of your policy. If you have questions about this summary of benefits (SOB), please call Prominence Health Plan Member Services at , or (TTY Operator Assistance) Our website,, also serves as an important resource and includes information about provider directories, urgent care and emergency care locations and more.

5 Except for an emergency, all health care services must be coordinated and obtained by a primary care practitioner (PCP) unless otherwise authorized. 1. Deductible - a set amount of covered charges occurring each calendar year which must be paid by the member before benefits are payable under this plan. Copays do not count towards the deductible. 2. Deductibles and copays accrue to the out-of-pocket maximum (OOPM). Use of the emergency room for non-emergency conditions cannot be used to satisfy the out-of-pocket maximum. Copay or copayment is the member share of cost that can be a specific dollar amount or a percentage of total fees as specified by this Schedule of Benefits. 3. Each member must choose a PCP who is responsible to provide, arrange and coordinate all of the health care services to assure continuity of care for you, and to initiate prior authorizations for specialized care you may require. 4. Prior authorization is the standard process of receiving approval for certain procedures and medical services to ensure that the requested medical care is appropriate and necessary. Not all services require a prior authorization from Prominence Health Plan. Your PCP (or specialist) obtains this on your behalf. For a complete list of services that require prior authorization, please visit or call to confirm if prior authorization has been obtained if required. 5. Durable medical equipment (DME) is covered when medically necessary, authorized by Prominence Health Plan and is in accordance with Medicare DME guidelines. 6. Ambulatory and day-surgery services performed in hospital or other facility. 7. Some services listed may be billed as diagnostic procedures, not preventive/screening procedures, which could require a member to pay the share of cost as listed under Radiology and Diagnostic Services. Diagnostic procedures are usually conducted when a member has already been diagnosed with an illness or disease, or a member is receiving follow-up treatment for an existing medical condition. In addition, a member share of cost might be incurred if additional procedures that are not listed on the Preventive Services list are conducted concurrently to the preventive service. 8. Some invasive diagnostic procedures are treated as outpatient hospital visits. 9. Pediatric Vision Coverage is provided for prescribed corrective lenses and eyeglass frames as follows: Frames and/or Prescribed Corrective Lenses including single vision, conventional (lined) bifocal, conventional (lined) trifocal, and lenticular. Lenses include glass or plastic lenses, all lens powers, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for children, monocular patients and patients with prescriptions > +/ diopters. Choosing your primary care practitioner (PCP) As a HMO member, you must select a primary care practitioner (PCP) to manage all of your medical care. If you have already selected a PCP, his or her name and contact number will appear on your member ID card. If Call for PCP is printed on your ID card, you must select a PCP by following the instructions below. How to select or change your PCP 1. Call Member Services at or (8 a.m. - 5 p.m. Pacific Time, Monday-Friday) 2. Be prepared to indicate your PCP selection to Member Services. You must use your selected PCP to manage your care If you see a primary care practitioner who is not your assigned PCP, your claim(s) may be denied. Always check with your PCP before seeking care from a specialist. Your PCP can help determine if specialty care (i.e., cardiology, gastroenterology, neurology, etc.) is needed. Access to pediatricians For children, you may designate a pediatrician as the primary care practitioner. Page 5

6 Access to OB/GYN physicians You do not need prior authorization from or from any other person (including a PCP) in order to obtain access to obstetrical or gynecological care from a healthcare professional in our network who specializes in obstetrics or gynecology. The healthcare professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating healthcare professionals who specialize in obstetrics or gynecology, contact Prominence Health Plan Member Services at and Terminations will not terminate coverage once a member is enrolled unless the individual (or a person seeking coverage on behalf of the individual) performs an intentional act, practice or omission that constitutes fraud, or unless the individual makes an intentional material misrepresentation of fact, as prohibited by the terms of the Evidence of Coverage. will provide at least 30 days advance written notice to each participant who would be affected before coverage will be terminated. Emergency Services are provided as follows: a. Without prior authorization requirement, even for out-of-network services; b. Without regard to whether the provider of the services is in-network; c. If the services are out-of-network, without any administrative requirements or coverage limitations that are more restrictive than those imposed on in-network services; and d. Without regard to any other tem or condition of the coverage other than: (1) the exclusion of or coordination of benefits; (2) an affiliation or waiting period permitted under ERISA, the PHSA, or the Internal Revenue Code; or (3) applicable cost sharing.

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