Amherst Central School District First Choice Health Plan. Non-First Choice Providers and Out-of-Network Providers

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1 Health: Hospital Services provided by First Choice Preferred Provider Network Medical Services Radiology, Ultrasounds 20% after $500 individual or Laboratory Testing 20% after $500 individual or MRI and CAT scans $20 copay 20% after $500 individual or Pre-authorization is required. Hospital Care Inpatient stay- semi private room 20% after $500 individual or Anesthesia 20% after $500 individual or Pre-certification is required. for specialty services rendered by the following providers: 1. Roswell Park Cancer Institute: Cancer treatment 2. Women & Children's Hospital: Pediatrics 3. Erie County Medical Center: Burn Treatment, Trauma Care, Transplant, Mental Health & Substance Abuse 4. BryLin Behavioral Health System: Mental Health & Substance Abuse Assistant Surgeon 20% after $500 individual or Services rendered by an Out-of-Network provider will be reimbursed at the In- Network benefit level when related services are In-Network. Hospital Physician Visits (Non- Mental Illness, Non-Substance Abuse Diagnosis) 20% after $500 individual or Visits by an out-of-network physician are limited to one per day per condition. Consultants by an out-of-network physician are limited to two consultations during a single inpatient confinement. Out-of-Network services will be reimbursed at the In-Network benefit when related services are In-Network Pre-Admission Testing 20% after $500 individual or Organ Transplants 20% after $500 individual or Surgical Expenses 20% after $500 individual or Blood, Blood Plasma & Oxygen 20% after $500 individual or Blood and/or plasma, if not replaced, and the equipment for its administration including autologous blood transfusions when performed at a participating facility where related surgery will be performed. Reconstructive Surgery 20% after $500 individual or Covered when medically necessary. Elective cosmetic surgery not covered. Outpatient surgery facility $75 copay 20% after $500 individual or Outpatient eye surgery facility $75 copay 20% after $500 individual or Chemotherapy, radiation therapy, inhalation therapy 20% after $500 individual or $20 copay for outpatient services rendered by Roswell Park Cancer Institute. Cardiac rehabilitation 20% after $500 individual or 36 visits per calendar year Page 1 of 5 05/21/2015

2 Health: Occupational, speech, physical therapy $20 copay 20% after $500 individual or 20 aggregate visits, per member, per plan year Emergency room visit $50 copay $50 copay Waived if admitted to hospital Emergency Ambulance $25 copay $25 copay Medically necessary Other Hospital-Based Services Home Health Care (Erie & Niagara Counties) $20 copay 20% after $500 individual or Limit to 40 visits. Professional Home Health care is not available for Pediatrics or mental health All Home Health Care visits must be pre-authorized in and out of network visits Hospice IH Provider - Private Duty Nursing Not covered Not covered Skilled nursing facility noncustodial Physician and Ancillary Services Provided by the Independent Health Physician Network Medical Services Office Visits Child: 20% after $500 individual or Specialist visits $20 copay 20% after $500 individual or Routine Physicals Not covered Well Child Visits and immunizations (to age 19) Bereavement counseling is available to family members either before or after death. Unlimited days. 20% after $500 individual or Limited to 45 days. Must be pre-authorized. Custodial care not covered. 20% after $500 individual or All well child visits must be provided in accordance with the standards and frequency schedule of the American Academy of Pediatrics. Covered Immunizations are as follows: Diphtheria; pertussis; tetanus; polio; measles; rubella; mumps; hemophilus influenza Allergy Testing & Injections $20 copay 20% after $500 individual or copay does not apply to the allergy serum. Temporomandibular Joint Disorders (TMJ) $20 copay 20% after $500 individual or Chiropractic Care $20 copay 20% after $500 individual or Maintenance care is not covered. Second Surgical Opinions $20 copay 20% after $500 individual or Podiatry $20 copay 20% after $500 individual or Physician visit coverage at 100% after copay. Routine services not covered. Page 2 of 5 05/21/2015

3 Health: Women s Services Mammograms Maternity Care (prenatal and postnatal care) Routine Gynecological office visits IH Provider - $50 copay $ 0 copay 20% after $500 individual or IH Provider - Out-of-Network Providers - 20% after $500 individual or Limited to the following: Age 35-39: one baseline; age 40-49: one mammogram up to once every two years, or more frequently upon the recommendation of a physician; age 50 and older: one mammogram in each calendar year. Limited to one per calendar year for women 18 years or older. Pap Smear $ 0 copay IH Provider - Out-of-Network Providers - 20% after $500 individual or Limited to one per calendar year for women 18 years or older. * *Out-of-network- a provider that is not the First Choice Network or not participating with Independent Health within the eight counties of Western New York Mental Health Care Inpatient 20% after $500 individual or Hospital Physician Visits (Mental Illness Diagnosis) Outpatient Biological Based Mental Illness 20% after $500 individual or Child: 20% after $500 individual or services rendered by the following specialty providers: 1. Erie County Medical Center 2. BryLin Behavioral Health System Substance Abuse Treatment Inpatient detoxification (detox only) 20% after $500 individual or Hospital Physician Visits (Alcohol Substance Abuse Diagnosis) Outpatient 20% after $500 individual or Child: 20% after $500 individual or services rendered by the following specialty providers: 1. Erie County Medical Center 2. BryLin Behavioral Health System Page 3 of 5 05/21/2015

4 Health: Other Physician/Ancillary Services Durable medical equipment Urgent Care Center Nutritional Supplements Prosthetic Devices 50% coinsurance $35 copay 50% coinsurance IH Provider - 50% IH Provider - $35 copay 20% after $500 individual or when provided with Home Infusion visit IH Provider - 50% copay Out-of Network Providers - Not covered Pre-authorization is required. $1,000 annual maximum Parenteral Nutrition covered in fullwith no visitation limit with Erie & Niagara Counties in conjunction with Home Infusion visit. Enteral Nutrition covered within Erie & Niagara Counties members ages 0-18, $20 copay applicable for members age 19 and older in conjunction with Home Infusion visit from a non- First Choice network provider. If provided as a prescription, applicable copay would apply. Not applicable for over-the-counter nutritional supplements purchased at retail. Pre-authorization is required. Biological based mental illness is defined as: a mental or nervous or emotional condition that is caused by a biological disorder of the brain and results in a clinically significant, psychological syndrome or pattern that substantially limits the function. * *Out-of-network- a provider that is not the First Choice Network or not participating with Independent Health within the 8 counties of WNY Vision Care Vision exam for each family member Frames Eye glass lenses Contact Lenses Prescription Benefits Low copays Free $40 off first pair Not covered Limited to one routine eye examination per calendar year when using a EyeMed participating network provider Generic Formulary/ Brand Formulary/ Non-Formulary $4 / $25 / $45 Not covered All Prescriptions paid under First Choice Prescription Drug Plan through Independent Health Pharmacy Benefit Dimensions Mail Order Prescription Drug $10 / $62.50 /$ Not Covered 90 day maintenance medication supply for 2.5 copays Page 4 of 5 05/21/2015

5 Health: Diabetic supplies and equipment Not covered Dependent Coverage Dependent Eligibility Age Limit 26 All eligible dependent children up to age 26 Deductible & Deductible Not applicable $500/$1,000 Coinsurance after deductible Not applicable 20% Health: In-Network Out-of-pocket maximum $2,500 / $5,000 $2,500/$5,000 Prescription Drug: In-Network Outof-pocket maximum $4,100 / $8,200 Not applicable Lifetime Maximum Unlimited Unlimited Biological based mental illness is defined as: a mental or nervous or emotional condition that is caused by a biological disorder of the brain and results in a clinically significant, psychological syndrome or pattern that substantially limits the function. * *Out-of-network- a provider that is not the First Choice Network or not participating with Independent Health within the 8 counties of WNY This summary represents a brief overview of benefits provided by the. Plan specific benefit information is detailed within the Plan Document. In the event of a discrepancy between this summary and the Plan Document, the Plan Document will prevail. Page 5 of 5 05/21/2015