Telemedicine services $0 copay Not applicable Primary care provider (PCP) CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance

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1 Calendar Year Deductible (CYD) 2 Plan includes an embedded individual deductible provision. An embedded deductible combines individual and family deductibles in $4,000 Single / $8,000 Family $12,000 Single / $24,000 Family soon as one member of the family reaches the individual deductible limit. Coinsurance 20% coinsurance 50% coinsurance Out-of-Pocket Maximum 3 - Deductibles, coinsurance and copays accrue toward the out-of-pocket maximum. Physician Office Visits $5,500 Single / $11,000 Family $16,500 Single / $33,000 Family Telemedicine services $0 copay Not applicable Primary care provider (PCP) Alternative Medicine - Homeopathy, acupuncture and integrated medicine. $1,500 maximum per calendar year; in-network and out-ofnetwork combined. Ambulance Services - Medically necessary only. Air ambulance CYD/20% Coinsurance CYD/20% Coinsurance Ground ambulance CYD/20% Coinsurance CYD/20% Coinsurance Durable Medical Equipment Rental or purchase Emergency Care - Includes surgeon and physician costs. admitted as an inpatient directly from the emergency room. If you receive services from an out-of-network provider, you may be amount the plan would have paid to an in-network provider. CYD/20% Coinsurance CYD/20% Coinsurance Urgent care Health and Wellness Services Online Wellness Assessment - OWA Link: prominencehealthplan.com Hearing Aids - Limited to one every three years. Home Health Care - Includes private-duty nursing. 8XPHSA4000SG Rev: 03/13/18 Page 1

2 Hospice Care Page 2 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. Hospital/Outpatient/Ambulatory Services 4 Inpatient Outpatient surgery Observation Inpatient skilled nursing - Up to 100 days per calendar year innetwork and out-of-network combined. Acute rehabilitation - Up to 60 days per calendar year in-network and out-of-network combined. Infertility Treatment Services procedure copay and/or coinsurance amount for any surgical infertility procedures performed. Infusion Therapy facility Performed and billed by a hospital outpatient facility In-network 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 nonstress tests and amniocentesis Medical Nutrition Therapy Counseling - Up to 25 visits per calendar year; in-network and out-of-network combined.

3 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 - Bariatric Gastric Restrictive surgery. One procedure per lifetime. Nutritional Supplements - Enteral therapy and parenteral nutrition. Maximum 120 days supply for special food products. Organ Transplants Covered under HMO only Ostomy Supplies - Per 30 day supply Pediatric Dental - Pediatric Dental Coverage up to Age 19 Out-of-Network Diagnostic and Preventive Services - Not subject to the deductible No Charge 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 3 - Subject to the deductible 50% Coinsurance 80% Coinsurance Preventive Services 5 - 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 Page 3

4 Prosthetics and Orthotics Prosthetics and orthotics - Foot orthotics limited to one pair per member per calendar year; in-network and out-of-network combined. Dental/Oral Orthotic Appliances, TMJ and/or Sleep Apnea Limited to one appliance per member per calendar year. Radiation Oncology Therapy Page 4 Hospital outpatient therapy facility fee Radiology and Diagnostic Services 6 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. Vision - Pediatric - Coverage up to age 19 Eye exam - Up to one routine eye exam per child per year. CYD/50% coinsurance Low-vision exam - Up to one routine eye exam per child per year. CYD/50% coinsurance Glasses - Up to one pair of basic frames and lenses. CYD/50% coinsurance Post-cataract services - Up to one pair of basic frames and lenses. CYD/20% coinsurance CYD/50% coinsurance

5 Prescription Coverage In-network Pharmacy FDA-approved formulary preventive medications, including female oral contraceptives $0 copay Generic Preferred brand Non-preferred brand Specialty drugs PharmacyPlus PharmacyPlus generic Not applicable PharmacyPlus brand Not applicable 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 disclosure statement provides only a brief description of some important features and limitations of your policy. The Certificate of Coverage (COC) sets forth in detail the rights and obligations of both you and the insurance company. It is important you review the COC once you are enrolled excess of the eligible medical expense (EME) charges and you could be responsible for all expenses over and above the EME. amount the plan will pay for a covered service. are payable under this plan. Copays do not count towards the deductible. 3. 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. 4. Hospital admissions and certain other services must be prior authorized by Preferred Health Care Utilization Management 5. 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. 6. Some invasive diagnostic procedures are treated as outpatient hospital visits. Establishing a Primary Care Provider (PCP) As a Prominence PPO member, you can choose from a comprehensive network of providers and services, from primary care providers (PCP), specialists, urgent care clinics, imaging centers, laboratories and more. We strongly encourage you to establish a relationship with a PCP, who can help manage your care and ensure timely receipt of recommended preventive care and other series that may be appropriate. Page 5

6 It is always a good idea to check with your PCP before seeking care from a specialist. Your PCP can help you 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 provider (PCP). Access to OB/GYN Physicians You do not need prior authorization from Company 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 including obtaining 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 at and Rescissions Company 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, of Coverage. Company will provide at least 30 days advance written notice to each 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. sharing. Out-of-network emergency services may be subject to additional charges above the allowable amount (what the plan would have paid an in-network provider). 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 the COC online at or call Customer Service and a copy can be mailed to you. Page 6