Schedule of Copayments and Deductibles

PriorityIndividualSM - EPO High Deductible Health Plan (HDHP) (HSA Compatible)

80% HOSPITAL SERVICES PLAN Your Policy provides you with important information about your health care benefits, including prior approval requirements. This Schedule of Copayments and Deductibles provides you with information about your costs when you receive health care services and the maximum limitations of your health care benefits. Read the entire Policy and Schedule of Copayments and Deductibles carefully. In accordance with the terms and conditions of the Policy, you are entitled to Covered Services when these services are: A. Medically/Clinically Necessary (as defined in the Policy and according to Medical and Behavioral Health policies established by Priority Health with the input of physicians not employed by Priority Health or according to criteria developed by reputable external sources and adopted by Priority Health); and B. Provided by your PCP or provided by a Participating Provider and with approval in advance by us when we consider approval necessary (except in a Medical Emergency) or provided by a Non-participating Provider (one not listed in our Provider Directory) upon referral from your PCP and approved in advance by us (except in a Medical Emergency); and C. Not excluded in the Policy. If you seek such services without a referral and prior approval when required, you will be responsible for the cost of the services. You will also be responsible for services that are beyond those approved, beyond benefit maximums or excluded from Coverage. IMPORTANT - Your Plan has a Deductible. The Deductible is the amount that must be paid before Priority Health will pay for Covered Services under this Policy. The Deductible applies to all Covered Services, except for certain preventive health care services. Coverage for preventive health care services is available after a waiting period of 180 consecutive days beginning on your most recent effective date of Coverage under this Policy.

Services

Benefits Note: Deductible applies to all Covered Services, except for certain preventive health care services

Hospital Services (Including radiology examinations and laboratory services) (See Other Referral Care section below for additional Copayment information.) Inpatient Hospital and Inpatient Longterm Acute 80% Coverage Care Services (Including observation care) Prior approval is required except in emergencies Outpatient Hospital Services (Including ambulatory 80% Coverage surgery center facility charges) Medical Emergency and Urgent Care Services 80% Coverage Emergency Room Services 80% Coverage Urgent Care Facility Services 80% Coverage Ambulance Services

Schedule of Copayments and Deductibles

Services

Physician Services (Primary and Referral Care) (See Other Referral Care section below for additional Copayment information.) Office/Home Visits and Consultations (face-to-face, telephonic, or through secure electronic portal by PCP, other Participating Physician) -Includes Covered visits not considered preventive health care Preventive Health Care Services – available after a waiting period of 180 consecutive days beginning on your most recenteffective date of Coverage under this Policy -Preventive health care services (except prenatal and pregnancy services) listed in Priority Health’s preventive health care guidelines. Covered preventive services must be provided and billed by your PCP or referred by your PCP. Maternity Services (Prenatal and Postnatal) Inpatient Hospital Visits Ambulatory Surgery Center Services Surgery Vasectomy Tubal Ligation

Benefits Note: Deductible applies to all Covered Services, except for certain preventive health care services

80% Coverage per PCP or other Participating Physician visit, including Specialist Provider

100% Coverage (available after a waiting period of 180 consecutive days beginning on your most recent effective date of Coverage under this Policy) Preventive health care services are limited to a $500.00 maximum benefit per member per Contract Year* Deductible does not apply Not Covered (including Physicians’ fees and any other related charges) 80% Coverage 80% Coverage 80% Coverage Not Covered (including Physicians’ fees and any other related charges) Not Covered (including Physicians’ fees and any other related charges)

Allergy Testing Allergy Injections Other Referral Care

80% Coverage 80% Coverage

Family Planning/Infertility Services

Not Covered (including Physicians’ fees and any other related charges) Not Covered (including Physicians’ fees and any other related charges) Not Covered (including Physicians’ fees and any other related charges)

Temporomandibular Joint Dysfunction or Syndrome Orthognathic Surgery

Schedule of Copayments and Deductibles

Services

Benefits Note: Deductible applies to all Covered Services, except for certain preventive health care services

Transplants

Not Covered (including Physicians’ fees and any other related charges Not Covered (including Physicians’ fees and any other related charges)

Certain Surgeries and Treatments Bariatric surgery and other medical weight loss services Reconstructive surgery o Blepharoplasty of upper lids o Breast reduction o Panniculectomy o Rhinoplasty o Septorhinoplasty o Surgical treatment of male gynecomastia Skin disorder treatments o Scar revisions o Keloid scar treatment o Treatment of hyperhidrosis o Excision of lipomas o Excision of seborrheic keratoses o Excision of skin tags o Treatment of vitiligo o Port wine stain and hemangioma treatment Varicose veins treatments Sleep apnea treatment procedures Dietitian Services

80% Coverage up to a benefit maximum of 6 visits per Contract Year *

Behavioral Health Services (Short-term therapy and crisis intervention) Prior approval by our Behavioral Health Department is required as noted. Call 616 464-8500 or 800 673-8043 Mental Health Inpatient 50% Coverage (Including partial hospitalization) Inpatient Mental Health benefits are limited to a maximum of $1,500.00 per member per Contract Year* Prior approval required Not Covered (including practitioner fees and any other Mental Health Outpatient related charges) Substance Abuse Care 50% Coverage up to a maximum benefit of $3,919.00 per member per Contract Year** Prior approval required

Schedule of Copayments and Deductibles

Services

Benefits Note: Deductible applies to all Covered Services, except for certain preventive health care services)

Rehabilitative Medicine Services (Including rehabilitative services provided in the home) Physical and Occupational Therapy (including osteopathic and chiropractic manipulation) Speech Therapy Cardiac Rehabilitation and Pulmonary Rehabilitation Other Services Radiology Examinations and Laboratory Procedures (In a non-hospital facility) Prosthetic and Orthotic/Support Devices

80% Coverage up to a combined benefit maximum of 5 visits per Contract Year* 80% Coverage up to a benefit maximum of 5 visits per Contract Year* 80% Coverage up to a combined benefit maximum of 5 visits per Contract Year* 80% Coverage Prior approval required for certain radiology examinations 50% Coverage Maximum combined benefit per Member per Contract year for Prosthetic and Orthotic/Support Devices and Durable Medical Equipment is $2,000.00 * Prior approval required for devices over $1,000.00

Durable Medical Equipment (Rent, purchase or repair)

50% Coverage Maximum combined benefit per Member per Contract Year for Prosthetic and Orthotic/Support Devices and Durable Medical Equipment is $2,000.00 * Prior approval required for equipment over $1,000.00

Facility Services (Non-hospital) Skilled Nursing Subacute Inpatient Rehabilitation Hospice Home Health Care (Including Hospice Services, excluding Rehabilitative Medicine)

80% Coverage up to a benefit maximum of 45 days per Contract Year* Prior approval required except for Hospice

Note: Rehabilitative services provided in the home are subject to the limitations of the Rehabilitative Medicine Services benefits described above.

80% Coverage up to a benefit maximum of 45 days per Contract Year* Prior approval required

Schedule of Copayments and Deductibles

Services

Benefits Note: Deductible applies to all Covered Services, except for certain preventive health care services)

Prescription Drug Benefits Medication Formulary. A list of both Generic and Brand Name Drugs, including Specialty Drugs, approved by Priority Health Pharmacy and Therapeutics Committee for use by our Members. Preferred Brand Name Drugs are usually Brand Name Drugs that have been on the market for a while or are commonly prescribed and have been selected based on their clinical effectiveness and safety. Non-preferred Brand Name Drugs are usually the highest cost drugs in a given category that have lower-cost alternatives with equal or better clinical effectiveness. Specialty Drug - Drugs listed in the Medication Formulary meeting certain criteria, such as drugs or drug classes whose cost on a per- month or per-dose basis exceeds the threshold established by the Centers for Medicare and Medicaid Services; or drugs that require special handling or administration; or drugs that have limited distribution; or drugs in selected therapeutic categories. Specialty Drugs are limited to a maximum of a 31-day supply per prescription or refill. Specialty Pharmacy - A Pharmacy that specializes in the handling, distribution, and patient management of Specialty Drugs. Retail Pharmacy Services (prescription drugs obtained at a retail Network Pharmacy, including oral contraceptives dispensed in a one-month supply per prescription or refill) In general, Covered retail pharmacy drugs are treated as outpatient prescription drug benefits when they can be self-administered regardless of the setting. Exceptions to this rule are outlined in our medical policies. Note: If you elect to receive a Brand Name Drug when the prescription allows a Generic Drug substitution, you may be responsible for difference in cost between the Generic Drug and the Brand Name Drug.

50% Copayment per prescription or refill for a Generic Drug on our Medication Formulary (31-day supply) 50% Copayment per prescription or refill for a Brand Name Drug on our Medication Formulary (31day supply) Self-administered injectable drugs must be obtained at a Network Pharmacy (including Participating Specialty Pharmacies for selected drug categories) Limitations and exclusions apply Maximum prescription drug benefit per Member per Contract Year for retail pharmacy service is $2,000.00 * Priority Health may require selected Specialty Drugs be obtained by your provider through a Specialty Pharmacy

Prior approval or step therapy may be required before drug will be Covered at applicable Copayment.

Drugs Covered Under Medical Plan (injectable and infusible drugs requiring administration by a Health Professional in a medical office, home or outpatient facility) In general, Covered drugs are treated as medical benefits when administered in an inpatient or emergency setting, or when the drug requires injection or infusion by a Health Professional. Exceptions to this rule are outlined in our medical policies. Step therapy may be required before drug will be Covered.

50% Coverage The maximum benefit per Member per Contract Year for Specialty Drugs administered by a Health Professional is $25,000.00 * Prior approval required for certain medications Priority Health may require selected Specialty Drugs be obtained by your provider through a Specialty Pharmacy

Schedule of Copayments and Deductibles

MAXIMUM LIMITATIONS AND PRE-EXISTING CONDITION EXCLUSION A. Benefit Maximums: *

Benefit Maximums: Benefit maximums up to a certain number of days/visits and/or dollar amount per Contract Year apply even when continued care is Medically/Clinically Necessary beyond the benefit maximum.

** Substance Abuse: Coverage is provided up to a minimum annual benefit as determined by the State of Michigan per Contract Year. Coverage amount to be adjusted each March 31 st in accordance with the average percentage increase in the “Consumer Price Index for All Urban Consumer-Revised” (CCPI). B. Maximum First Year Benefit and Maximum Lifetime Benefit: $100,000.00 is the maximum benefit per Member for all Covered services in the first Contract Year. $1,000,000.00 is the maximum lifetime benefit per Member for all Covered Services. C. Pre-Existing Condition Exclusion: Benefits are excluded for each Illness or Injury, or any other condition, for which, during the twelve month period prior to your most recent effective date, medical advice, diagnosis, care or treatment was recommended by or received from a Health Professional. For purposes of this limitation, “treatment” includes the use of prescription drugs. Genetic information is not treated as a Pre-Existing Condition in the absence of a diagnosis of a condition related to the genetic information. This exclusion will apply until the end of the twelve-month period beginning on your most recent effective date under this Policy. The Pre-Existing Condition exclusion does not apply to a newborn who becomes a Covered Dependent under this Policy within 31 days after the birth. DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM A. Deductibles: The Deductible is the amount of medical and prescription drug Covered Services you must incur during the Contract Year before benefits will be paid. The Deductible is applicable to all Covered Services except preventive health care services that are listed in Priority Health’s preventive health care guidelines when the services are provided and billed by your PCP or referred by your PCP. Coverage for preventive health care services is available after a waiting period of 180 consecutive days of Coverage from your most recent effective date under this Policy. Priority Health’s preventive health care guidelines were developed and approved by Priority Health network physicians. These guidelines are available on our Web site at priority-health.com or you may request a copy from our Customer Service Department. Note: This Policy does not Cover prenatal and pregnancy services listed in the preventive health care guidelines. Subscriber Only Contract and Subscriber Plus Dependent(s) Contract Deductibles: If you are the only individual on your contract, you have a Subscriber Only Contract and the Subscriber Only Contract Deductible below applies. If you have more than one individual on your contract, you have a Subscriber Plus Dependent(s) Contract and only the Subscriber Plus Dependent(s) Contract Deductible applies. The Subscriber Plus Dependent(s) Contract Deductible can be satisfied by any one family member or by any combination of family members. Your Deductible renews each Contract Year. Your Deductible will take into account any monies paid under your prescription benefits. Notwithstanding the above, your Deductible will not take into account: any monies you paid for non-Covered Services; and any monies you paid for Covered Services that exceed the annual day or dollar benefit maximum for a specific benefit and therefore, denied as non-Covered Services; and

Schedule of Copayments and Deductibles

any monies you paid for Covered Services after the Lifetime Benefit Maximum is exhausted. Deductibles Subscriber Only Contract Subscriber Plus Dependent(s) Contract

$2,000.00 $4,000.00

B. Out-of-Pocket Maximums: The Out-of-Pocket Maximum limits the total amount that you will pay toward medical Covered Services during a Contract Year. If you have a Subscriber Only Contract, when calculating your Out-of-Pocket Maximum, we will include all Copayments and Deductibles you paid toward Covered Services during a Contract Year. If you have a Subscriber Plus Dependent(s) Contract, we will include all Copayments and Deductibles you and your family paid collectively toward Covered Services during a Contract Year. Once the applicable Out-of-Pocket Maximum is met, all further medical Covered Services for that Contract Year will be paid by Priority Health at 100% without requirement of Copayment, until you meet the benefit maximums described above. Your Out-of-Pocket Maximum will take into account any monies paid under your prescription drug benefits. Notwithstanding the above, your Out-of-Pocket Maximum will not take into account: any monies you paid for non-Covered Services; and any monies you paid for Covered Services that exceed the annual day or dollar benefit maximum for a specific benefit and therefore, denied as non-Covered Services; and any monies you paid in the first Contract Year for Covered Services after the First Year Benefit Maximum is exhausted; and any monies you paid for Covered Services after the Lifetime Benefit Maximum is exhausted.

Out-of-Pocket Maximums Subscriber Only Contract Subscriber Plus Dependent(s) Contract Created: 2009 Doc_ 1862

$ 5,800.00 $11,600.00