SCHEDULE OF BENEFITS

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SCHEDULE OF BENEFITS

Premier Health Plan Premier HealthOne Bronze 5500 Health Maintenance Organization (HMO)

Individual Certificate of Coverage

This schedule of benefits (SOB) is part of your Certificate of Coverage (COC) but does not replace it. Many words are defined elsewhere in the COC, and other limitations or exclusions may be listed in other sections of the COC.

This SOB lists Your cost sharing obligations and other important information that apply to the services you receive under Your Plan. You should review this SOB to become familiar with Your cost sharing obligations and any limits that apply to the services.

If You have any questions about this COC or want more information about Your benefits or Us, contact Member Services at the phone number on the back of Your Member ID Card or write to:

Premier Health Plan 110 N. Main Street

Suite 1200 Dayton, OH 45402

Premier Health Plan

Benefits In-Network

Benefit Year Deductible

Per individual $5,500

Per family

If an individual member meets the individual deductible, the plan will begin to pay benefits for that specific member, even if the family deductible is not met

$11,000

Coinsurance (Percent paid by You)

% Coinsurance, after Deductible 30%

Benefit Year Out-of-Pocket Limit

Per individual $6,600

Per family

If an individual member meets the individual out-of-pocket limit, the plan will pay benefits for that specific member, even if the family out-of-pocket limit is not met

$13,200 Covered Services

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Preventive care Paid in full

Child health supervision services Paid in full

Periodic health examinations Paid in full

Annual gynecology examination Paid in full

Contraceptive benefits Paid in full

Prostate screening Paid in full

Illness or Injury

Office visit $30 copay

After hours care $30 copay

Specialty care doctor office visit 30% coinsurance after deductible

Allergy Treatment 30% coinsurance after deductible

Allergy Testing 30% coinsurance after deductible

Maternity Care

Maternity care (prenatal/postnatal visits) 30% coinsurance after deductible

Inpatient delivery and other maternity care services $750 copay and 30% coinsurance after deductible

Complications of pregnancy 30% coinsurance after deductible

Sterilization 30% coinsurance after deductible

Emergency Room Services

Life-threatening illness or serious accidental injury $200 copay and 30% coinsurance after deductible

Non-emergency use of the emergency room Not Covered

Urgent care services $75 copay

Inpatient Services

Daily room, board and general nursing care $750 copay and 30% coinsurance after deductible

Physician services 30% coinsurance after deductible

Assistant surgery 30% coinsurance after deductible

Outpatient Services

Surgery facility/hospital charges 30% coinsurance after deductible

Advanced imaging and diagnostic services 30% coinsurance after deductible

Physician services 30% coinsurance after deductible

Assistant surgery 30% coinsurance after deductible

Therapy Services

Manipulation Therapy/Chiropractic Care (limit of 12 visits/year) 30% coinsurance after deductible

Dialysis treatment 30% coinsurance after deductible

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Habilitative services

(limit of 20 visits/year for each outpatient physical rehabilitation service; limit of 20 hours/week for clinical therapeutic intervention)

30% coinsurance after deductible

Outpatient rehabilitation services (combined limit of 116 visits/year for physical therapy, occupational therapy, speech therapy, respiratory therapy and cardiac rehabilitation)

Cardiac rehabilitation (limit of 36 visits/year) 30% coinsurance after deductible Occupational therapy (limit of 20 visits/year) 30% coinsurance after deductible Physical therapy (limit of 20 visits/year) 30% coinsurance after deductible Respiratory therapy (limit of 20 visits/year) 30% coinsurance after deductible Speech therapy (limit of 20 visits/year) 30% coinsurance after deductible

Chemotherapy and radiation 30% coinsurance after deductible

Mental Health/Substance Abuse Services

Inpatient services $500 copay and 30% coinsurance after deductible

Partial hospitalization 30% coinsurance after deductible

Intensive outpatient treatment or day treatment $30 copay/visit and 30% coinsurance after deductible for other outpatient services

Outpatient treatment or individual or group treatment $30 copay/visit and 30% coinsurance after deductible for other outpatient services

Residential treatment services $500 copay and 30% coinsurance after deductible Other Services

Ambulance 30% coinsurance after deductible

Breast cancer patient care 30% coinsurance after deductible

Cancer clinical trials 30% coinsurance after deductible

Clinical trial programs required by the Affordable Care Act 30% coinsurance after deductible

Consultation services 30% coinsurance after deductible

Dental services related to accidental injury ($3,000/occurrence) 30% coinsurance after deductible Diabetic equipment, education and supplies 30% coinsurance after deductible

Durable medical equipment 30% coinsurance after deductible

General anesthesia services 30% coinsurance after deductible

Home health care (limit of 100 visits/year) 30% coinsurance after deductible

Hospice care 30% coinsurance after deductible

Infertility services 30% coinsurance after deductible

Medical supplies 30% coinsurance after deductible

Nutritional counseling 30% coinsurance after deductible

Private duty nursing (limit of 90-] visits/year) 30% coinsurance after deductible

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Prosthetics Appliances 30% coinsurance after deductible

Reconstructive surgery 30% coinsurance after deductible

Skilled nursing facility care (limit of 90 days/year) 30% coinsurance after deductible Temporomandibular or Craniomandibular Joint Disorder and

Craniomandibular Jaw Disorder 30% coinsurance after deductible

Telemedicine Payable in accordance with the type of expense

incurred and the place of service.

Vision correction (cataract or aphakia treatment) 30% coinsurance after deductible Transplant Services

Organ transplants 30% coinsurance after deductible

Unrelated donor searches for bone marrow/stem cell

transplants 30% coinsurance after deductible; Limit of up to

$30,0000 per transplant

Travel and lodging for organ transplants 30% coinsurance after deductible; Limit of up to

$10,0000 per transplant Pediatric Vision Services

Eye exam for Children (Limit of 1 visit/year) No charge

Glasses or contacts (1 pair of glasses (lenses and frames) or

contact lenses/year*) No charge

*See Certificate of Coverage for limitations on glasses or contact lenses.

Prescription Drug - Certain preventive medications may be covered at no cost, please see formulary for more information

Retail

(up to 30-day supply)

Mail Order

(up to 90-day supply)

Pharmacy Deductible Integrated with Medical Deductible (Except for

generic drugs, must meet calendar year deductible before the plan begins to pay pharmacy benefits)

Preferred Generic $15 copay *or less $37.50 copay *or less

Non-preferred generic $25 copay *or less $62.50 copay *or less

Preferred brand 30% coinsurance after

deductible *or less 30% coinsurance after deductible *or less

Non-preferred brand 35% coinsurance after

deductible *or less

35% coinsurance after deductible *or less

Specialty 35% coinsurance after

deductible *or less 35% coinsurance after deductible *or less

*There are situations where the cost of the drug could be less than your cost sharing. Please refer to the Prescription Drug benefit in Your Certificate of Coverage

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Verification of Benefits

Verification of benefits is available for Members or Providers on behalf of Members. You may call Member Services with a benefits inquiry during normal business hours, [7 a.m. to 7 p.m. eastern time Monday through Friday, and 8 a.m. to 3 p.m. on Saturdays].

Please remember that a benefits inquiry is NOT a verification of coverage of a specific medical procedure.

 Verification of benefits is NOT a guarantee of payment

 If the verified service requires Prior Authorization, please call [phone number]