COVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions:

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1 Exhibit D-3 HMO 1000 Coverage Schedule ROCKY MOUNTAIN HEALTH PLANS GOOD HEALTH HMO $1000 DEDUCTIBLE / 75 PLAN EVIDENCE OF COVERAGE LARGE GROUP Underwritten by Rocky Mountain Health Maintenance Organization, Inc. COVERAGE SCHEDULE Benefits are subject to the Cost Sharing, Yearly Out-of-Pocket Maximums, and Maximum Benefit Levels shown in this Coverage Schedule. Please refer to Your Contract for a description of Your Benefits, Limitations, and Exclusions. Benefits are subject to all terms of the Contract. This is a non-federally qualified health care plan. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions: L Maximum Benefit Level Limitation Exclusion Not a Benefit of the Contract Benefits are subject to the following: Deductible a) Member b) Subscriber and Dependents Amounts paid by You to satisfy the Deductible will apply to the Yearly Out-of-Pocket Maximum. Deductible must be met before services will be covered, except as noted. s do not apply to the Deductible. Yearly Out-of-Pocket Maximum a) Member b) Subscriber and Dependents All s apply to the Yearly Out-of-Pocket Maximum, except s for Neuromusculoskeletal (NM) services. a) $1,000 per Calendar Year b) $2,000 per Calendar Year a) $4,500 per Calendar Year b) $9,000 per Calendar Year BENEFITS The Benefits listed below are subject to s until the Yearly Out-of-Pocket Maximum is satisfied, unless otherwise noted. Due to HIPAA requirements, We do not always share Cost Sharing amounts owed to Us with health care providers. Information that a health care provider has regarding Cost Sharing amounts owed may not accurately reflect amounts that You owe to Us. HMO_GH_LG_NGF_CS_1000/75_ Page 1 of 8

2 Care not shown on this Coverage Schedule Alcohol and Substance Abuse Detox L - Limited to removal of toxic substances from the body. a) Inpatient Care b) Outpatient Care Alcohol and Substance Abuse Rehab a) Inpatient and other facility based Care b) Outpatient Care Ambulance Services Asthma Education outpatient Autism Spectrum Disorders (ASD) - The yearly Maximum Benefit Level for Applied Behavior Analysis for ASD is: 550 sessions* birth through age 8; 185 sessions* age 9 through age 18; or such other amounts as required by Colorado law. *A session is a 25 minute period of time Blood Services outpatient Colorectal Cancer Screenings outpatient (Including screening colonoscopies, screening sigmoidoscopies, removal of polyps during the screening and fecal occult blood tests) Related services (anesthesia, laboratory services, medical supplies and radiology) are included in the colorectal cancer screening benefit. Cost Sharing may apply for non-preventive Care provided at the same visit. Diabetic Education outpatient Dialysis outpatient a) b) $45 per visit a) b) $45 per visit No Benefit level determined by place and type of service No No HMO_GH_LG_NGF_CS_1000/75_ Page 2 of 8

3 Disposable Medical Supplies a) Picked up from a pharmacy and listed on the RMHP Formulary L - Subject to quantity limits noted in the RMHP Formulary. b) All other Disposable Medical Supplies Durable Medical Equipment (DME) and Repairs a) Picked up from a pharmacy and listed on the RMHP Formulary on Tier 1 Tier 5 b) Picked up from a pharmacy and listed on the RMHP Formulary on Tier 6 c) Breast pumps and supplies L Covered with the birth of a child. L Rental or purchase is covered up to the cost of the RMHP Preferred Model. d) All other Durable Medical Equipment Office visit may apply Early Intervention Services (EIS) - 45 therapeutic visits per Member per Calendar Year. a) 20%, not to exceed $150 per claim b) a) See the Prescription Drug Supplement included with this Contract b) 20%, not to exceed $150 per claim c) Rental or purchase: No d) No Any therapy Benefits received as part of EIS are not subject to and will not apply to the Maximum Benefit Levels for other therapy services under this Contract L - EIS are only a Benefit for Members who are under age 3. Emergency Room Care Enteral Nutrition L - Covered for Members up to age 3. a) Picked up from a pharmacy b) Not picked up from a pharmacy Eyeglasses and Contact Lenses L Covered when required as a result of eye surgery or with a diagnosis of keratoconus. a) 20%, not to exceed $150 per claim up to a 31- day supply b) HMO_GH_LG_NGF_CS_1000/75_ Page 3 of 8

4 Family Planning and Sterilization a) Any medically acceptable device or procedure used to prevent pregnancy not listed below b) Counseling and information on birth control Birth control for women c) Diaphragms d) IUDs and subdermal implants e) Hormone injections f) Surgical sterilization for women g) Prescription drugs and devices picked up from a pharmacy a) Subject to the for type of service provided b) f) No g) See the Prescription Drug Supplement included with this Contract h) Subject to the for type of service provided Birth control for men h) Surgical sterilization for men Over-the-counter contraceptive drugs or devices which do not require a prescription, except those listed as included in the RMHP Formulary. Home Health Services - 60 visits per Member per Calendar Year. Hospice Services inpatient and outpatient - Respite Care is limited to periods of 5 days or less. Hospital inpatient and outpatient (Applies to all Hospital Care unless otherwise provided in this Coverage Schedule) Injectable and Infusion Drugs Self-Administerable a) Obtained from a pharmacy b) Received in a Physician s office or outpatient facility Injectable and Infusion Drugs Non Self-Administerable 25% a) See the Prescription Drug Supplement included with this Contract b) Not covered a) & b) a) Obtained from a pharmacy b) Not obtained from a pharmacy HMO_GH_LG_NGF_CS_1000/75_ Page 4 of 8

5 Laboratory Services outpatient Maternity Care a) Routine prenatal Care, delivery, and inpatient wellbaby Care b) Non-routine maternity services Medical Foods and Therapeutic Formulas a) Picked up from a pharmacy b) Not picked up from a pharmacy Mental Health Services - Mental Illness and Mental Disorders a) Inpatient Care b) Outpatient Care Neuromusculoskeletal (NM) Services Office Visits (Applies to all office visit Care unless otherwise provided in this Coverage Schedule) a) PCP b) Any other Network Provider Related services are subject to the Cost Sharing for the type Visits at an outpatient facility will be subject to the Cost Sharing in addition to any office visit. $25 per visit a) b) Benefit level determined by place and type of service a) 20%, not to exceed $150 per claim up to a 31- day supply b) a) b) $45 per visit See the NM Services Supplement, if included with this Contract does not apply to the Yearly Out-of-Pocket Maximum, and will remain payable after the Yearly Out-of-Pocket Maximum is met. a) $45 per visit b) $60 per visit HMO_GH_LG_NGF_CS_1000/75_ Page 5 of 8

6 Oxygen Service outpatient Physician Services Physician s office and outpatient facility Care. Prescription Drugs outpatient L -Subject to Limitations noted in the RMHP Formulary and Prescription Drug Supplement. Preventive Cancer Screenings outpatient - One per type of service per Member per Calendar Year. Cost Sharing may apply for non-preventive Care provided at the same visit. a) Mammograms (preventive or diagnostic) b) Prostate screenings c) Routine pap smears (cervical cancer screenings) See the Prescription Drug Supplement a c) No HMO_GH_LG_NGF_CS_1000/75_ Page 6 of 8

7 Preventive Services outpatient Cost Sharing may apply for non-preventive Care provided at the same visit. a) Adult physical exams and routine gynecological exams - One per type of service per Member per Calendar Year, except for additional preventive services recommended by a Physician. b) Well baby Care, well child Care and child health supervision services, not including immunizations L - Well child services as age appropriate. c) Immunizations - Adult and child immunizations, vaccination for cervical cancer, and influenza and pneumococcal immunizations as recommended by ACIP - Travel immunizations d) Alcohol misuse screening and behavioral counseling interventions for adults per the A or B USPSTF recommendations e) Tobacco use screening for adults by any primary care provider per the A or B USPSTF recommendations. Tobacco cessation interventions for adults through the Colorado Quitline (or other provider We specify) per the A or B USPSTF recommendations f) Cholesterol screening for lipid disorders g) Chlamydia screening, for female Members within the ages of the USPSTF recommendation h) Any preventive service not listed above included: as an A or B USPSTF recommendations; in the women s preventive care and screening guidelines supported by HRSA; or a - h) No in the infants, children, and adolescents preventive care and screenings guidelines supported by HRSA. Prosthetic Devices (PD) and Orthotic Devices (OD) (Including repairs) Psychological Testing outpatient Radiation Therapy Skilled Nursing Facility Services - 60 days per Member per Calendar Year. Covered as a mental health service HMO_GH_LG_NGF_CS_1000/75_ Page 7 of 8

8 Surgery inpatient, outpatient surgery and invasive diagnostic testing Therapy Services inpatient physical, speech, occupational therapy, cardiac and pulmonary rehabilitation - Physical, occupational and speech therapies (combined) are limited to 2 months per Episode per medical condition. Therapy Services outpatient a) Physical, occupational and speech therapy - Physical, occupational and speech therapies are limited to 20 visits per Member per therapy per Calendar Year. - Therapies (physical, occupational and speech) for congenital defects and birth abnormalities (for Members up to 6 years of age) - 20 visits for each type of therapy per Member per Calendar Year, reduced by the number of other physical, occupational and speech therapy Benefits received by the Member in a Calendar Year for the same condition. b) Cardiac and pulmonary rehabilitation Total Parenteral Nutrition (TPN) outpatient Transplants inpatient and outpatient Urgent Care Services outpatient (In and out of Service Area) Vision Screening outpatient - One per Member per Calendar Year. X-ray and Other Imaging Services outpatient a) X-rays and other imaging b) MRI, PET and CT scans a) $60 per visit b) $60 per visit $45 per visit a) $50 per visit b) HMO_GH_LG_NGF_CS_1000/75_ Page 8 of 8

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