LOW PLAN MAXIMUM BENEFIT AMOUNT: Aggregate Annual Limit NETWORK PROVIDERS NOTE: Benefits are only covered at Network Providers. No coverage is available at NON-NETWORK Providers, except where indicated Unlimited DEDUCTIBLE, PER CALENDAR YEAR Per Covered Person $3,000 Per Family Unit $6,000 The Calendar Year deductible is waived for the following Covered Charges: - Preventive Care Services - Any benefit for which a copayment applies MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR (not including penalties and prescription drug copayments ) Per Covered Person $6,350 Per Family Unit $12,700 The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year. COVERED CHARGES Hospital Services Room and Board Intensive Care Unit Emergency Room Visit Medical Emergency (Coverage at Network or Non-Network Providers) Urgent Care Visit Skilled Nursing Facility Hospital's ICU Charge the facility's semiprivate room rate within seven days of a Hospital confinement 30 days Calendar Year Physician Services Inpatient visits Office visits Specialist office visits Surgery Allergy testing Allergy serum and injections 30 visits Calendar Year Diagnostic Testing (X-ray & Lab) Home Health Care 120 days Calendar Year Hospice Care 6 months Lifetime Bereavement Counseling Six visits Lifetime Ambulance Service 100% Jaw Joint/TMJ $1,000 Calendar Year 1
LOW PLAN NETWORK PROVIDERS NOTE: Benefits are only covered at Network Providers. No coverage is available at NON-NETWORK Providers. Wig After Chemotherapy Occupational Therapy Speech Therapy Physical Therapy Durable Medical Equipment Orthotics s are Prosthetics Orthotics s are Orthotics Orthotics s are Spinal Manipulation Chiropractic 20 visits Calendar Year Mental Disorders Inpatient Outpatient Substance Abuse Inpatient Outpatient Preventive Care Routine Well Adult Care 100% (Age 19 and over) Includes: office visits, pap smear, mammogram, gynecological exam, routine physical examination, laboratory tests, immunizations/flu shots, obesity/weight loss program, tobacco cessation program and colonoscopies. Frequency limits for mammogram Ages 40 and over... annually Routine Well Newborn Care (in-hospital) Routine Well Child Care 100% Includes: office visits, routine physical 60% after examination, deductible laboratory tests, vision tests, immunizations and other preventive care and services required by applicable law if provided by a Panel/Network/Participating Provider through age 18. Visits per Calendar Year Ages 0-1... 7 visits Ages 1-2... 2 visits Ages 2-18... 1 visit Organ Transplants Only at Center of Excellence Pregnancy Dependent daughters not covered. 2
LOW PLAN Pharmacy Option (30 Day Supply) Generic $25 copayment Formulary Brand Name $45 copayment Non-Formulary Brand Name 50% Mail Order Option (90 Day Supply) Generic $50 copayment Formulary Brand Name $90 copayment Non-Formulary Brand Name 50% PRESCRIPTION DRUG BENEFIT SCHEDULE PRESCRIPTION DRUG BENEFIT NOTE: MANDATORY MAIL ORDER The Plan covers only the initial fill and one (1) refill, if required, under the Pharmacy Option. Any additional refills must be purchased through the Express Scripts Mail Order Program mail service option in order to be covered under this Plan. 3
MAXIMUM BENEFIT AMOUNT: Aggregate Annual Limit SENIOR MED, LLC EMPLOYEE BENEFIT PLAN BASIC PLAN NETWORK PROVIDERS Unlimited NON-NETWORK PROVIDERS Note: The s listed below are the total for Network and Non-Network expenses. For example, if a of 60 days is listed twice under a service, the Calendar Year is 60 days total which may be split between Network and Non-Network providers. DEDUCTIBLE, PER CALENDAR YEAR Per Covered Person $2,000 $6,000 Per Family Unit $4,000 $18,000 The Calendar Year deductible is waived for the following Covered Charges: - Preventive Care Services - Any benefit for which a copayment applies COPAYMENTS Physician visits $35 N/A Specialist visits $50 N/A Emergency room $250 $250 Urgent care visit $50 N/A The Emergency room copayment is waived if the patient is admitted to the Hospital on an emergency basis. The utilization review administrator, Hines & Associates, Inc. must be notified at (800) 735-1200 within seven days of the admission, even if the patient is discharged within seven days of the admission. MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR (not including penalties and Prescription copayments) Per Covered Person $6,350 $12,700 Per Family Unit $12,700 $38,100 The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year. COVERED CHARGES Hospital Services Room and Board Intensive Care Unit Emergency Room Visit Medical Emergency (Waived if admitted) Hospital's ICU Charge Hospital's ICU Charge $250 copayment $250 copayment Urgent Care Visit $50 copayment Skilled Nursing Facility the facility's semiprivate room rate within seven days of a Hospital confinement 30 days Calendar Year the facility's semiprivate room rate within seven days of a Hospital confinement 30 days Calendar Year Physician Services Inpatient visits Office visits $35 copayment Specialist office visits $50 copayment Surgery Allergy testing $50 copayment 1
BASIC PLAN NETWORK PROVIDERS NON-NETWORK PROVIDERS Allergy serum and injections $50 copayment 30 visits Calendar Year 30 visits Calendar Year Diagnostic Testing (X-ray & $35 copayment Lab) Home Health Care 120 days Calendar Year 120 days Calendar Year Hospice Care 6 months Lifetime 6 months Lifetime Bereavement Counseling $50 copayment Six visits Lifetime Six visits Lifetime Ambulance Service 100% 100% Jaw Joint/TMJ $1,000 Calendar Year Wig After Chemotherapy $50 copayment Occupational Therapy $50 copayment Speech Therapy $50 copayment Physical Therapy $50 copayment Durable Medical Equipment Orthotics s are Prosthetics Orthotics s are Orthotics Orthotics s are Spinal Manipulation Chiropractic $50 copayment 20 visits Calendar Year $1,000 Calendar Year 20 visits Calendar Year Mental Disorders Inpatient Outpatient $50 copayment Substance Abuse Inpatient Outpatient $50 copayment 2
BASIC PLAN NETWORK PROVIDERS NON-NETWORK PROVIDERS Preventive Care Routine Well Adult Care (Age 19 and over) 100% Includes: office visits, pap smear, mammogram, gynecological exam, routine physical examination, laboratory tests, immunizations/flu shots, obesity/weight loss program, tobacco cessation program and colonoscopies. Frequency limits for mammogram Ages 40 and over... annually Routine Well Newborn Care (in-hospital) Routine Well Child Care 100% Includes: office visits, routine physical examination, laboratory tests, vision tests, immunizations and other preventive care and services required by applicable law if provided by a Panel/Network/Participating Provider through age 18. Visits per Calendar Year Ages 0-1... 7 visits Ages 1-2... 2 visits Ages 2-18... 1 visit Organ Transplants Not Covered Only at Center of Excellence Pregnancy $35 copayment Dependent daughters not covered. PRESCRIPTION DRUG BENEFIT SCHEDULE PRESCRIPTION DRUG BENEFIT NETWORK NON-NETWORK Pharmacy Option (30 Day Supply) Generic $25 copayment Prescriptions are only covered Formulary Brand Name $45 copayment Prescriptions are only covered Non-Formulary Brand Name 50% Prescriptions are only covered Mail Order Option (90 Day Supply) Generic $50 copayment Not Applicable Formulary Brand Name $90 copayment Not Applicable Non-Formulary Brand Name 50% Not Applicable NOTE: MANDATORY MAIL ORDER The Plan covers only the initial fill and one (1) refill, if required, under the Pharmacy Option. Any additional refills must be purchased through the Express Scripts Mail Order Program mail service option in order to be covered under this Plan. 3
MAXIMUM BENEFIT AMOUNT: Aggregate Annual Limit SENIOR MED, LLC EMPLOYEE BENEFIT PLAN PREMIUM PLAN NETWORK PROVIDERS Unlimited NON-NETWORK PROVIDERS Note: The s listed below are the total for Network and Non-Network expenses. For example, if a of 60 days is listed twice under a service, the Calendar Year is 60 days total which may be split between Network and Non-Network providers. DEDUCTIBLE, PER CALENDAR YEAR Per Covered Person $1,000 $4,000 Per Family Unit $2,250 $12,000 The Calendar Year deductible is waived for the following Covered Charges: - Preventive Care Services - Any benefit for which a copayment applies COPAYMENTS Physician visits $25 N/A Specialist visits $40 N/A Emergency room $250 $250 Urgent care visit $40 N/A The Emergency room copayment is waived if the patient is admitted to the Hospital on an emergency basis. The utilization review administrator, Hines & Associates, Inc. must be notified at (800) 735-1200 within seven days of the admission, even if the patient is discharged within seven days of the admission. MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR (not including penalties and prescription drug copayments) Per Covered Person $3,000 $12,000 Per Family Unit $6,000 $36,000 The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year. COVERED CHARGES Hospital Services Room and Board Intensive Care Unit Emergency Room Visit Medical Emergency (Waived if admitted) Hospital's ICU Charge Hospital's ICU Charge $250 copayment $250 copayment Urgent Care Visit $40 copayment Skilled Nursing Facility the facility's semiprivate room rate within seven days of a Hospital confinement 30 days Calendar Year the facility's semiprivate room rate within seven days of a Hospital confinement 30 days Calendar Year Physician Services Inpatient visits Office visits $25 copayment Specialist office visits $40 copayment Surgery Allergy testing $40 copayment 1
PREMIUM PLAN NETWORK PROVIDERS NON-NETWORK PROVIDERS Allergy serum and injections $40 copayment 30 visits Calendar Year 30 visits Calendar Year Diagnostic Testing (X-ray & $25 copayment Lab) Home Health Care 120 days Calendar Year 120 days Calendar Year Hospice Care 6 months Lifetime 6 months Lifetime Bereavement Counseling $40 copayment Six visits Lifetime Ambulance Service 100% 100% Jaw Joint/TMJ $1,000 Calendar Year Wig After Chemotherapy $40 copayment Occupational Therapy $40 copayment Speech Therapy $40 copayment Physical Therapy $40 copayment Durable Medical Equipment Orthotics s are Prosthetics Orthotics s are Orthotics Orthotics s are Spinal Manipulation Chiropractic $40 copayment 20 visits Calendar Year Six visits Lifetime $1,000 Calendar Year 20 visits Calendar Year Mental Disorders Inpatient Outpatient $40 copayment Substance Abuse Inpatient Outpatient $40 copayment 2
PREMIUM PLAN NETWORK PROVIDERS NON-NETWORK PROVIDERS Preventive Care Routine Well Adult Care (Age 19 and over) 100% Includes: office visits, pap smear, mammogram, gynecological exam, routine physical examination, laboratory tests, immunizations/flu shots, obesity/weight loss program, tobacco cessation program and colonoscopies. Frequency limits for mammogram Ages 40 and over... annually Routine Well Newborn Care (in-hospital) Routine Well Child Care 100% Includes: office visits, routine physical examination, laboratory tests, vision tests, immunizations and other preventive care and services required by applicable law if provided by a Panel/Network/Participating Provider through age 18. Visits per Calendar Year Ages 0-1... 7 visits Ages 1-2... 2 visits Ages 2-18... 1 visit Organ Transplants Not Covered Only at Center of Excellence Pregnancy $25 copayment Dependent daughters not covered. PRESCRIPTION DRUG BENEFIT SCHEDULE PRESCRIPTION DRUG BENEFIT NETWORK NON-NETWORK Pharmacy Option (30 Day Supply) Generic $25 copayment Prescriptions are only covered Formulary Brand Name $45 copayment Prescriptions are only covered Non-Formulary Brand Name 50% Prescriptions are only covered Mail Order Option (90 Day Supply) Generic $50 copayment Not Applicable Formulary Brand Name $90 copayment Not Applicable Non-Formulary Brand Name 50% Not Applicable NOTE: MANDATORY MAIL ORDER The Plan covers only the initial fill and one (1) refill, if required, under the Pharmacy Option. Any additional refills must be purchased through the Express Scripts Mail Order Program mail service option in order to be covered under this Plan. 3