Calendar Year Deductible (CYD) 1 an embedded individual deductible provision. An embedded deductible combines

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1 Calendar Year Deductible (CYD) 1 an embedded individual deductible provision. An embedded deductible combines Summary of Benefits $4,000 Single / $8,000 Family deductible limit. Coinsurance - Deductibles, coinsurance and copays accrue toward the out-of-pocket maximum. With respect to family plans, an individual is only subject to the individual 20% individual out-of-pocket maximum amount, then the family out-of-pocket maximum amount is met. Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue toward the $5,500 Single / $11,000 Family out-of-pocket maximum. 2 Provider Office Visits Telemedicine services $ 0 copay Primary care provider (PCP) 3 4 Alternative Medicine - Homeopathy, acupuncture and integrated medicine. $1,500 maximum per calendar year. Ambulance Services - Medically necessary only. Air ambulance Ground ambulance Durable Medical Equipment 5 Rental or purchase Emergency Care - Includes surgeon and physician charges. inpatient directly from the emergency room. If you receive services from an outamount the plan would have paid to an in-network provider. Urgent care Health and Wellness Services Online Wellness Assessment - OWA Link: prominencehealthplan.com Hearing Aids - Limit one every three years. Home Health Care - Includes private-duty nursing. Hospice Care Hospice care Respite inpatient - Up to 10 days per 6 months. Respite outpatient - Up to 10 visits per year. Bereavement services - Up to 5 visits per year. 8XHMOHD4000SG Rev: 03/13/18 Page 1

2 Hospital/Outpatient/Ambulatory Services 6 Inpatient Outpatient surgery Observation - No additional copay if transferred from outpatient surgery. Inpatient skilled nursing - Up to 100 days per calendar year. Acute rehabilitation - Up to 60 visits per condition per member per calendar year. Infertility Treatment Services coinsurance amount for any surgical infertility procedures performed. Infusion Therapy Page 2 Performed and billed by a hospital outpatient facility Specialty drugs incur 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 - Up to 25 visits per calendar year. Mental Health Services Severe Mental Illness Inpatient Day treatment program Outpatient General Mental Health Alcohol and Drug Abuse Services Inpatient withdrawal Inpatient rehabilitation Outpatient rehabilitation/day treatment Morbid Obesity - Includes inpatient or outpatient services. One procedure per lifetime.

3 Nutritional Supplements - Enteral therapy and parenteral nutrition. Maximum 120 days supply for special food products. Organ Transplants Ostomy Supplies Pediatric Dental - Pediatric Dental Coverage up to age 19 In-Network Out-of-Network Diagnostic and Preventive Services - Not subject to the deductible 30% Coinsurance Basic Restorative Procedures - Subject to the deductible 20% Coinsurance 50% Coinsurance Major Restorative Procedures - Subject to the deductible 50% Coinsurance 80% Coinsurance Orthodontia - Subject to the deductible 50% Coinsurance 80% Coinsurance Preventive Services 7 - For a complete list of covered services, visit 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 Prosthetics and Orthotics Prosthetics and orthotics - Foot orthotics up to one pair per member per calendar year. Dental/oral orthotic appliances, TMJ and/or sleep apnea. Up to one appliance per member per calendar year. Radiation Oncology Therapy Hospital outpatient therapy facility fee Radiology and Diagnostic Services 8 Routine X-ray and Routine Diagnostic Tests Imaging and Complex Diagnostic Tests Spinal Manipulation - Includes all covered services related to the spinal manipulation. Up to 26 Visits per year. Temporomandibular Joint Dysfunction TMJ surgery - inpatient hospital Therapies Physical, occupational and speech - Up to 60 visits per condition per member per calendar year. Habilitative - Up to 60 visits per condition per member per calendar year. Rehabilitative - Up to 60 visits per condition per member per calendar year. Autism spectrum disorders - Up to 750 hours per member per calendar year. Page 3

4 Vision - Pediatric - Coverage up to age 19 Eye exam - Up to one routine eye exam per child per year. Low-vision exam - Up to one routine eye exam per child per year. Glasses - Up to one pair of basic frames and lenses. Post-cataract services - Up to one pair of basic frames and lenses. $100 copay Prescription Coverage In-network Pharmacy FDA-approved preventive medications, including female oral contraceptives Generic Preferred brand Non-preferred brand Specialty drugs PharmacyPlus PharmacyPlus generic PharmacyPlus brand 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. The Evidence of Coverage (EOC) sets forth in detail the rights and obligations of both you and the insurance company. It is important you review the EOC once you are enrolled , 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. Except for an emergency, all health care services must be coordinated and obtained by a primary care provider (PCP) unless otherwise authorized. 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 1. are payable under this plan. Copays do not count towards the deductible. 2. Deductibles, coinsurance and copays accrue to the out-of-pocket maximum (OOPM). Use of the emergency room for nonemergency conditions cannot be used to satisfy the out-of-pocket maximum. 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. Members may be required to obtain a primary care practitioner (PCP) referral to see a specialist. 5. Durable medical equipment (DME) is covered when medically necessary, authorized by Prominence Health Plan and is in accordance with Medicare DME guidelines. Page 4

5 Summary of Benefits 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. Choosing your primary care provider (PCP) As a HMO member, you must select a primary care provider (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 Be prepared to indicate your PCP selection to Customer Service. 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. If you see a specialist without a referral, your claim(s) may be denied. Access to pediatricians For children, you may designate a pediatrician as the primary care practitioner. 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 health care professional in our network who specializes in obstetrics prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Prominence Health Plan Customer Service. Rescissions will not rescind 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. Prominence be rescinded. 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. cost sharing. Out-of-network emergency services may be subject to additional charges above the allowable amount (what plan would have paid an in-network provider). Page 5

6 Language Translation Services information. Servicios de traducción de idiomas Esta infomación está disponible gratuitamente en otros idiomas. Por favor llame al departamento de servicio de miembros al (TTY: 711) para mas información. Notice of Privacy Practices Member privacy and security are important to Prominence Health Plan. For comprehensive information about how we protect your personal health information (PHI) and how it may be disclosed, refer to the Evidence of Coverage (EOC). You can access the EOC online at or call Customer Service and a copy can be mailed to you. Page 6