Schedule of Benefits Harvard Pilgrim Health Care, Inc.

Schedule of Benefits Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM-LAHEY SELECT HMO OOA MASSACHUSETTS 6-SPF, 01/13 MD0000002737 Please Note: In this plan, Member s have access to network benefits only from the providers in the Harvard Pilgrim-Lahey Select network. This network includes a tiered provider network. In this plan, Members pay different levels of Copayments or Coinsurance depending on the tier of the provider delivering a covered service or supply. Please consult the Harvard Pilgrim-Lahey Select Provider Directory or visit the provider search tool at www.harvardpilgrim.org/lahey to determine the tier of Providers in the Harvard Pilgrim-Lahey Select Network. This Schedule of Benefits summarizes your Benefits under The Harvard Pilgrim Lahey-Select HMO (the Plan) and states the Member Cost Sharing amounts that you must pay for Covered Benefits. This is only a summary of your benefits. Please see your Benefit Handbook for detailed information on benefits covered by the Plan and the terms and conditions of coverage. This plan does not provide coverage for outpatient prescription drugs. Your coverage for prescription drugs is administered by a third party named CVS Caremark. If you have questions regarding your pharmacy coverage, CVS Caremark can be reached at 1-800-237-2767. Services are covered when Medically Necessary. Subject to the exceptions listed in the section of the Benefit Handbook titled, How the Plan Works all services must be (1) provided or arranged by your Primary Care Provider (PCP) and (2) provided by a Harvard Pilgrim-Lahey Select Plan Provider. These requirements do not apply to care needed in a Medical Emergency. You always have coverage for care in a Medical Emergency. A Referral from your PCP is not needed. In a Medical Emergency, you should go to the nearest emergency facility or call 911 or other local emergency number. Your emergency room Member Cost Sharing is listed below under the heading Emergency Room Care. We use clinical review criteria to evaluate whether certain services or procedures are Medically Necessary for a Member s care. Members or their practitioners may obtain a copy of our clinical review criteria applicable to a service or procedure for which coverage is requested. Clinical review criteria may be obtained by calling 1-888-888-4742 ext. 38723. Your Covered Benefits are administered on a calendar year basis. Your calendar year begins on January 1 st and ends on December 31 st of each year. MEMBER COST SHARING Members are required to share the cost of the Covered Benefits provided under the Plan. This section describes the payments for which you are responsible, called Member Cost Sharing. The tables, set forth below, show the specific Member Cost Sharing amounts for the different services covered by the Plan. 1

PREVENTIVE SERVICES No Member Cost Sharing applies to certain preventive services when received by an adult from a Tier 1 or Tier 2 provider. For pediatrics (up to age 19), there is no Member Cost Sharing when received from a Tier 1, Tier 2 or Tier 3 provider. These services are summarized below and further described in the tables later in this Schedule of Benefits: Annual preventive gynecological examinations Immunizations Specified Preventive services and tests Routine prenatal and routine postpartum care Routine well physical examinations (including well child care, vision and auditory screening for children, and health education) TIERED PROVIDERS Most hospitals and physicians covered by the Plan are placed into one of three benefit levels or tiers. Member Cost Sharing for these providers depends upon the tier in which a provider is placed. Tier 1 and Tier 2 are the lower cost tiers, and Tier 3 is the higher cost tier. Only acute care hospitals, Primary Care Provider (PCPs) and medical specialists are assigned to one of three tiers. All other covered providers are assigned to Tier 2. In some cases, a provider may practice at more than one location and may have a different tier assigned to each location. Keep in mind that different out-of-pocket costs may apply to the same provider based upon where you are treated by that provider. You can lower your out-of-pocket cost by selecting the physicians and hospitals in the lower tiers. The tables set forth below list the Member Cost Sharing for each type of tiered service. The Plan s Provider Directory lists all Plan Providers and their associated tier. You can access the Provider Directory at www.harvardpilgrim.org/lahey. Please note: When you choose a PCP, it is important to consider the tier of the hospital that your PCP uses. For example, a Tier 2 PCP may admit patients to a Tier 3 Hospital. COINSURANCE Coinsurance is a percentage of the cost for certain services that is payable by the Member. COPAYMENTS A Copayment is a fixed dollar amount that is payable by the Member for certain covered services. Copayments are due at the time services are rendered or when billed by the provider. Different Copayments apply depending on the type of service, the tier placement of the provider and the location of service. 2

DEDUCTIBLES A Deductible is a specific annual dollar amount that is payable by the Member for Covered Benefits received each calendar year before any benefits subject to the Deductible are payable by the Plan. If a family Deductible applies, it is met when any combination of Members in a covered family incur expenses for services to which the Deductible applies. Your Plan s Deductible amounts are listed on page 4. The Deductible applies only to certain services in Tier 3 under the Plan. You can learn about the services that require payment of a Deductible and the amounts from the tables below. Deductible amounts are incurred on the date of service. Your Plan has both an individual Deductible and a family Deductible. However, the family Deductible only applies if you have family coverage. Unless a family Deductible applies, you are responsible for the individual Deductible for Covered Benefits each calendar year. If you have family coverage, the Deductible can be satisfied in one of two ways: 1. If a Member of a covered family meets the individual Deductible, then services for that Member that are subject to that Deductible are covered by the Plan for the remainder of the calendar year. 2. If any number of Members in a covered family collectively meet the family Deductible, then all Members of the covered family are deemed to have met the Deductible for the remainder of the calendar year. Any Deductible amount incurred for any Covered Service during a calendar year will apply toward the Deductible for that year. For example, a Member incurred a Deductible for care in a Tier 3 hospital in January. The Deductible amount incurred in January will apply toward the Deductible payable under the Plan for any Covered Service received later in the calendar year. Once the Deductible is met, no further Deductible applies for the remainder of the calendar year. However, coverage by the Plan remains subject to any other Member Cost Sharing that may apply. OUT-OF-POCKET MAXIMUM You have an Annual Out-of-Pocket Maximum of $3,000 per Member or $6,000 per family, which includes Emergency Room Copayments, Deductible and Coinsurance. Cost sharing that applies to the Out-of-Pocket Maximum will accumulate across all tiers. Copayment for office visits, Physical, Occupational, and Speech Therapy, and outpatient prescription drugs, and any charges in excess of the Usual, Customary and Reasonable Charge do not apply to the Out-of-Pocket Maximum. 3

Coinsurance None 20% Coinsurance Office Visit Copayments Pediatric (up to age 19) Your Plan has a $15 Copayment per visit Your Plan has a $15 Copayment per visit Adult Your Plan has a $15 Copayment per visit Your Plan has a $75 Copayment per visit Deductible Out-of-Pocket Maximum Includes the following Cost Sharing: Emergency Room Copayment, Deductible and Coinsurance. Cost sharing that applies to the Out-of-Pocket Maximum will accumulate across all tiers. Excludes the following cost sharing: Copayments for office visit, Physical, Occupational and Speech Therapies, and Copayments for outpatient prescription drugs. None $3,000 per Member per calendar year $6,000 per family per calendar year $1,000 per Member per calendar year $2,000 per family per calendar year 4

Ambulance Transport Emergency ambulance transport Non-emergency ambulance transport Autism Spectrum Disorders Treatment j Professional Services Coverage for the treatment of Autism Spectrum Disorders is provided for all of the services otherwise covered under your Plan. However, no benefit limit applies to services for the treatment of Autism Spectrum Disorders. Applied Behavior Analysis $15 Copayment No benefit limit applies to this service Cardiac Rehab $15 Copayment per visit $35 Copayment per visit Chemotherapy - Outpatient $35 Copayment per visit Clinical Trials for the Treatment of Cancer Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Dental Services Emergency dental care Extraction of teeth impacted in bone (when done in an office setting) Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided in a dentist s office, see Physician and Other Professional Office Visits. For services provided in a hospital emergency room, see Emergency Room Care. $15 Copayment per visit 5

Dental Services (continued) Preventive Dental $15 Copayment per visit Care for children (up to age 13) Diabetes Services and Supplies Self management and training/diabetic eye examinations/foot care $15 Copayment per visit $75 Copayment per visit Dialysis Diabetes equipment Pharmacy supplies Your medical plan does not provide coverage for outpatient prescription drugs. For questions on prescription drug coverage, please contact CVS Caremark at 800-237-2767. $35 Copayment For Hospital Inpatient dialysis services, please see Hospital Inpatient Services for your Member Cost Sharing. Installation of home equipment is covered up to $300 in a Member's lifetime. Durable Medical Equipment and Prosthetic Devices Early Intervention Services $15 Copayment per visit Emergency Admission Services Emergency Room Care $100 Copayment per visit Family Planning Services This Copayment is waived if admitted to the hospital directly from the emergency room. Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. 6

Hearing Aids (for Members up to the age of 22) Limited to No charge $2,000 per hearing aid every 36 months, for each hearing impaired ear Home Health Care Hospice Services Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services or Skilled Nursing Facility Care. Hospital Inpatient Services j 20% Coinsurance after Deductible has been met House Calls $15 Copayment per visit $75 Copayment per visit Human Organ Transplant Services Hypodermic Syringes and Needles $15 Copayment for Pediatrics (up to age 19) Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Your medical plan does not provide coverage for outpatient prescription drugs. For questions on prescription drug coverage, please contact CVS Caremark at 800-237-2767. 7

Infertility Treatments (see the Benefit Handbook for details)j 20% Coinsurance after Deductible has been met Laboratory and Radiology Services Hospital based and Non-hospital based laboratory and x-rays Non-hospital based High End Radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services) Hospital based High End Radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services) 20% Coinsurance after Deductible has been met No Member Cost Sharing applies to certain preventive care services. See Preventive Services and Tests, below. Low Protein Foods j Limited to $5,000 per calendar year 8

Maternity Care Routine outpatient prenatal and postpartum care Preventive services and screenings including: counseling about alcohol and tobacco use, services to promote breastfeeding, routine urinalysis and screenings for the following: asymptomatic bacteriuria; hepatitis B infection; HIV and screenings for STDs chlamydia, gonorrhea and syphilis); iron deficiency anemia; and Rh (D) incompatibility. $75 Copayment per visit Please see Preventive Services and Tests, on page 12, for additional services and tests covered with no Member Cost Sharing. Please note: Routine prenatal and postpartum care is usually received and billed from the same Provider as a single or bundled service. Different Member Cost Sharing may apply to any specialized or nonroutine service that is billed separately from your routine outpatient prenatal and postpartum care. For example, for services provided by another physician or specialist, see Physician and Other Professional Office Visits for your applicable Member Cost Sharing. Please see your Benefit Handbook for more information on maternity care. Routine and non-routine nursery care for the newborn, including prophylactic medication to prevent gonorrhea and screenings for the following: hearing loss; congenital hypothyroidism; phenylketonuria (PKU); and sickle cell disease. 20% Coinsurance after Deductible has been met Hospital inpatient services 20% Coinsurance after Deductible has been met Please Note: If a newborn is released from the hospital and re-admitted at a later date, the cost sharing will follow that of Hospital Inpatient Services 9

Medical Formulas Mental Health Care (Including the Treatment of Substance Abuse Disorders)j Please note: This Plan is subject to Federal Mental Health Parity Inpatient Mental Health Care Services Intermediate Mental Health Care Services Acute residential treatment (including detoxification), crisis stabilization and in-home family stabilization Intensive outpatient programs, partial hospitalization and day treatment programs Outpatient Mental Health Care Services Group therapy: $15 Copayment per visit Individual therapy: $15 Copayment per visit Detoxification $15 Copayment per visit Medication management $15 Copayment per visit Psychological testing and neuropsychological assessment Performed by a Licensed Mental Health Professional $15 Copayment per visit Performed by a Neurologist or other medical specialist Ostomy Supplies $15 Copayment per visit $75 Copayment per visit $15 Copayment for Pediatrics (up to age 19) 10

Physician and Other Professional Office Visits (This includes all covered Providers unless otherwise listed in this Schedule of Benefits)j Routine examinations for preventive care Routine physical examinations, annual gynecological examinations, school, camp, sports and premarital examinations Routine hearing examinations and tests Health education No Member Cost Sharing applies to certain preventive care services. See Preventive Services and Tests, on page 12. $75 Copayment per Visit for Pediatrics (up to age 19) Sickness and injury care Examinations and Consultations, including: Medication management Nutritional counseling Administration of allergy injections $15 Copayment per visit $75 Copayment per visit $10 Copayment per visit $15 Copayment for Pediatrics (up to age 19) 11

Preventive Services and Tests j This benefit is limited to the preventive laboratory and pathology tests and screenings as defined by federal law. No Member Cost Sharing applies to the following services when provided to an adult by a Tier 1 or Tier 2 provider. For pediatrics (up to age 19), there is no Member Cost Sharing when provided by a Tier 1, Tier 2 or Tier 3 provider. Abdominal aortic aneurysm screening (for males 65-75 one time only, if ever smoked) Alcohol misuse screening and counseling (primary care visits only) Aspirin for the prevention of heart disease (primary care counseling only) Autism screening (for children at 18 and 24 months of age primary care visits only) Behavioral assessments (developmental surveillance, for children of all ages primary care visits only) Blood pressure screening Breast cancer chemoprevention counseling (only for women at high risk for Breast Cancer and low risk for adverse effects of chemoprevention) Breast cancer screening, including mammograms and genetic susceptibility screening Cervical cancer screening, including pap smears Cholesterol screening (for adults only) Colorectal cancer screening, including colonoscopy, sigmoidoscopy and fecal occult blood test Depression screening (primary care visits only) Diabetes screenings Diet counseling Dyslipidemia screening (for children at high risk for higher lipid levels) Hemoglobin A1c Hepatitis B testing HIV screening Immunizations, including flu shots (for children and adults as appropriate) Iron deficiency prevention (primary care counseling for children age 6 to 12 months only) Lead screening (for children at risk) Microalbuminuria test Obesity screening Osteoporosis screening (to begin at age 60 for women at increased risk) Ovarian cancer susceptibility screening Sexually transmitted diseases STDs screenings and counseling Tobacco use counseling (primary care visits only) Total cholesterol tests Tuberculosis skin testing Vision screening (children to age 5 only) Please see the Maternity Care benefit for additional services and tests covered with no Member Cost Sharing. Under federal law the list of preventive services and tests covered under this benefit may change periodically based on the recommendations of the following agencies: a. Grade A and B recommendations of the United States Preventive Services Task Force; b. With respect to immunizations, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and c. With respect to services for woman, infants, children and adolescents, the Health Resources and Services Administration. Information on the recommendations of these agencies may be found on the web site of the US Department of Health and Human Services at: http://www.healthcare.gov/center/regulations/prevention/recommendations.html. Harvard Pilgrim will add or delete services from this benefit for preventive services and tests in accordance with changes in the recommendations of the agencies listed above. 12

Radiation Treatment - Outpatient $35 Copayment per visit Reconstructive Surgery Rehabilitation Hospital Care - Limited to 60 days per calendar year Your Member Cost Sharing will depend upon the types of services provided and the tier placement of the provider rendering services, as listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Rehabilitation Therapy - Outpatient Occupational therapy - Limited to 30 visits per calendar year Physical therapy - Limited to 30 visits per calendar year Pulmonary rehabilitation therapy $15 Copayment per visit $35 Copayment per visit Scopic Procedures - Outpatient Diagnostic and Therapeutic Colonoscopy, endoscopy and sigmoidoscopy No Member Cost Sharing applies to certain preventive care services. See Preventive Services and Tests, listed on page 12. Skilled Nursing Facility Care - Limited to 100 days per Your Member Cost Sharing will depend upon where the service is provided and the tier placement of the provider rendering services, as listed in this Schedule of Benefits. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. calendar year Speech-Language and Hearing Services Speech Therapy $15 Copayment per visit $35 Copayment per visit 13

Surgery Outpatient 20% Coinsurance after Deductible has been met Temporomandibular Joint Dysfunction Services (medical treatment only)j Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Vision Services Routine eye examinations - Limited to (1 per calendar year) $15 Copayment per visit $75 Copayment per visit $15 Copayment for Pediatrics (up to age 19) Vision hardware for special conditions (see the Benefit Handbook for details) Voluntary Sterilization Your Member Cost Sharing will depend upon where the service is listed in this Schedule of Benefits. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services Voluntary Termination of Pregnancy Your Member Cost Sharing will depend upon where the service is listed in this Schedule of Benefits. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services Wigs and Scalp Hair Prostheses when needed as a result of any form of cancer or leukemia, alopecia areata, alopecia totalis or permanent hair loss due to injury j - Limited to $350 per calendar year (see the Benefit Handbook for details) 14