PLAN CODE: 3000A-10 MERCY HEALTH PLANS SCHEDULE OF COVERAGE AND BENEFITS

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PPO INDIVIDUAL HDHP/HSA PLAN

- Requires Prior Authorization. Refer to Your Policy for details.

PLAN CODE: 3000A-10

MERCY HEALTH PLANS

SCHEDULE OF COVERAGE AND BENEFITS

With Mercy Health Plans’ PPO, You can choose to receive either Network Benefits or Non-Network Benefits. To obtain Network Benefits You must see a Network Physician or other Network Provider. You must show Your identification card (ID card) every time You request health care services from a Network Provider. If You do not show Your ID card, Network Providers have no way of knowing that You are enrolled under a Mercy Health Plans’ PPO Policy. As a result, they may bill You for the entire cost of the services You receive. Please refer to Your Policy for a detailed

explanation of covered and non-covered services, as well as Prior Authorization requirements. Just because a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under this Schedule of Coverage and Benefits. All capitalized terms shall have the meaning assigned to them in Your Policy.

AMOUNT PAYMENT INFORMATION

NETWORK NON-NETWORK

MEDICAL SERVICES

AnnualDeductible - Combined Medical and Pharmacy

The Deductible must be met before medical or pharmacy Benefits are payable, except for preventive health/wellness services, routine immunizations. Coinsurances are not included in Your Deductible.

$3,000 per Covered Person per Calendar Year, not to exceed $6,000 for all Covered Persons in a family.

$6,000 per Covered Person per Calendar Year, not to exceed $12,000 for all Covered Persons in a family.

Out-of-Pocket Maximum – Combined Medical & Pharmacy

Only Coinsurances apply towards Your Out-of-Pocket Maximum. Coinsurance is the amount You pay after You meet Your Deductible.

$0 per Covered Person per Calendar Year, not to exceed

$0 for all Covered Persons in a

family. Out-of-Pocket Maximum does not

include the Annual Deductible.

$1,500 per Covered Person per Calendar Year, not to exceed $3,000

for all Covered Persons

in a family. Out-of-Pocket Maximum

does not include the Annual Deductible.

Maximum Policy Benefit No Maximum Policy Benefit No Maximum Policy Benefit

MEMBER RESPONSIBILITY SERVICES

Alcoholism/Chemical Dependency Services 

• Outpatient services - 26 days each Calendar Year.

• Residential Treatment Program - 21 days each Calendar Year.

• Detoxification in a medical or social setting - 6 days eachCalendar Year. Coverage is provided for 10 Episodes of treatment per lifetime. This limitation will not apply to Benefits received for medical detoxification for a life-threatening situation. In this case, Benefits are payable even after the ten (10) Episode limit is reached if both of the following conditions are met: • The Episode is determined to be

life-threatening by the treating Physician and • The Episode is documented as life

threatening to Our satisfaction within forty-eight (48) hours after treatment is given.

Outpatient Services:

0% Coinsurance after Deductible Residential Treatment Program: 0% Coinsurance after Deductible Inpatient Services:

0% Coinsurance after Deductible

Outpatient Services:

25% Coinsurance after Deductible Residential Treatment Program: 25% Coinsurance after Deductible Inpatient Services:

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Plan Code: 3000A-10 PPO INDIVIDUAL HDHP/HSA PLAN MEMBER RESPONSIBILITY

SERVICES

Allergy Services

•

Office Visits

•

Injections/Treatment

Office Visit:

0% Coinsurance after Deductible per office visit for Primary care

0% Coinsurance after Deductible per office visit for Specialist care

Injections/Treatment:

Office Visit:

Injections/Treatment

25% Coinsurance after Deductible Ambulance Services - Emergency Only

•

Ground Transportation

•

Air Transportation

Ground Transportation: 0% Coinsurance after Deductible Air Transportation:

0% Coinsurance after Deductible per transport

Ground Transportation: 0% Coinsurance after Deductible Air Transportation:

0% Coinsurance after Deductible per transport Clinical Trials – Cancer

Coverage is only available for the routine patient care costs related to the phase II, III or IV clinical trials.

0% Coinsurance after Deductible 25% Coinsurance after Deductible

Dental Anesthesia and Facility Charges  Coverage is limited to:

• A child under the age of five (5); or • A Covered Person who is severely disabled;

or

• A Covered Person has a medical or behavioral condition that requires hospitalization or general anesthesia when dental care is provided.

Dental Services - Accident only  Initial contact with a Physician or dentist must have occurred within 72 hours of the accident. In no case will accidental dental coverage extend more than 12 months from the date of Injury. Any further visits for post-Emergency treatment must be pre-approved by the Plan.

Diabetes Services 

Medically appropriate and necessary equipment, supplies and self-management training for the management and treatment of diabetes. Services are provided for persons with gestational, type I or type II diabetes.

Dialysis

Covered In Network Only

0% Coinsurance after Deductible Covered In Network Only

Durable Medical Equipment  See Health Reform Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND 5-10)

See Health Reform Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND 5-10)

Emergency Room Services 0% Coinsurance after Deductible 0% Coinsurance after Deductible

Eye Examinations (Routine Only) .

See Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits: (PHI MO/INDIV AMEND 3-09)

Hearing Screenings for Newborns 0% Coinsurance after Deductible 25% Coinsurance after Deductible

Home Health Care 

Services received from a Home Health Agency that are ordered by a physician,

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SERVICES

provided by or supervised by a registered nurse in Your home, and You are Homebound or Your physical or mental condition pose a serious and significant impediment to receiving medically necessary services outside the home. Benefits are available only when the Home Health Agency services are provided on a part-time, intermittent schedule and when skilled care is required.

Coverage is limited to a maximum of 60 visits per Calendar Year.

Hospice/Palliative Care 

Benefit is available once per lifetime for a terminally ill person with a life expectancy of less than six (6) months. Coverage is limited to a hundred-and-eighty (180) days during the entire period of time You are covered under this Policy.

Human Leukocyte Antigen Testing - For bone marrow transplantation donor

Immunizations (Routine Only) See Health Reform Amendment to the 2008

and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND 5-10)

Injectables/Infusions 

(received in a physician’s office, infusion center or through home health)

A list of injectables/infusions requiring Prior Authorization can be obtained at

www.mercyhealthplans.com or by calling Our Customer Contact Center at the number listed on Your ID card.

0% Coinsurance after deductible per

injectable/infusion

25% Coinsurance after Deductible per injectable/infusion

Inpatient Hospital Services  Semi-private room covered.

Mental Health Services 

Any combination of Network and Non-Network Benefits is limited as follows: Outpatient Mental Health :

90 visits regardless of the length of each session.

Intensive Outpatient Program (IOP): Intensive outpatient program (IOP) visits are included in the outpatient mental health visit limit listed above.

Residential Treatment Program: Up to a maximum of 90 days per Calendar Year

Inpatient Mental Health Services: There is no limit on inpatient mental health services.

Outpatient Mental Health Visits: 0% Coinsurance after Deductible

Intensive Outpatient Program (IOP): 0% Coinsurance after Deductible

Residential Treatment Program: 0% Coinsurance after Deductible

Inpatient Mental Health Services: 0% Coinsurance after Deductible

Outpatient Mental Health Visits: 25% Coinsurance after Deductible

Intensive Outpatient Program (IOP): 25% Coinsurance after Deductible

Residential Treatment Program: 25% Coinsurance after Deductible

Inpatient Mental Health Services: 25% Coinsurance after Deductible

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SERVICES

Partial Hospital Treatment Program: There is no limit on partial hospital treatment services.

Partial Hospital Treatment Program: 0% Coinsurance after Deductible

Partial Hospital Treatment Program: 25% Coinsurance after Deductible

Neuropsychological Testing  See Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits: (PHI MO/INDIV AMEND 3-09)

Nutritional Counseling

Up to three (3) visits per Calendar Year for only certain conditions as limited in Your Policy.

Nutritional Supplements 

Covered benefit only when tube feeding (enteral administration) using nutritional supplements is the sole source of a member’s nutrition for a permanent condition, or when parenteral (intravenous administration) nutritional requirements exists (i.e., hyperemesis of pregnancy) under certain conditions.

Observation Care 

Coverage for up to 48 hours. We must pre-approve services that exceed one (1) day stay.

Orthotics  See Health Reform Amendment to the 2008

and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND 5-10)

Osteoporosis Services/Bone Mineral

Density (BMD) Testing 

Outpatient Diagnostics  See Amendment to the 2008 and 2009

Individual Schedule of Coverage and Benefits: (PHI MO/INDIV AMEND 3-09)

Outpatient Surgery/ Hospital

Procedures

Physician’s Office Services 0% Coinsurance after Deductible per visit to a

PCP

0% Coinsurance after Deductible per visit to a Specialist

No office visit Copayment applies when no Physician charge is assessed.

PKU Formula and Low Protein Modified Food Products for Metabolic Disorders Coverage for the treatment of

phenylketonuria (PKU) or any inherited disease of amino and organic acids. Applies to children under age six (6).

Preventive Health/Wellness Services See Health Reform Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND 5-10)

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SERVICES

Professional Fees for Surgical and Medical Services

Prosthetic Devices  See Health Reform Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND 5-10)

Reconstructive Procedures 

See Your Policy for coverage description and limitations.

Rehabilitation Services See Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits: (PHI MO/INDIV AMEND 3-09)

Skilled Nursing Facility (SNF) 

Any combination of Network and Non-Network Benefits is limited up to a maximum

of 60

days per Calendar Year.

Tobacco Cessation Education Program $0 Copayment per program Covered In Network Only Transplant Services 

We have specific guidelines regarding Benefits for transplant services. Contact Us at the telephone number on Your ID card for information about these guidelines.

0% Coinsurance after Deductible Covered In Network Only

Urgent Care Center Services Covered Health Services received at an Urgent Care Center that are required to prevent serious deterioration of Your health within twenty-four (24) hours of the onset of an unforeseen Sickness, Injury, or the onset of acute or severe symptoms

When services to treat urgent health care needs are provided in a Physician's office, Benefits are available as described under Physician’s Office Services above.

RIDERS

Birth Control Services See Amendment to the 2008 and 2009 Individual Schedule of Coverage and Benefits: (PHI MO/INDIV AMEND 3-09

Outpatient Prescription Drug

Note: If a Prescription Drug is prescribed in a single dosage amount for which the

particular Prescription Drug is not

manufactured in such single dosage amount and requires dispensing the particular Prescription Drug in a combination of different manufactured dosage amounts, We will only impose one co-payment for the dispensing of the combination of manufactured dosages that equal the prescribed dosage for such Prescription Drug.

Your Annual Deductible noted above must be satisfied before Benefits are payable under this Rider

NETWORK:

•

0% Coinsurance after Deductible for up to a 30-day supply of Tier One drugs

•

0% Coinsurance after Deductible for up to a 30-day supply of Tier Two drugs

•

0% Coinsurance after Deductible for up to a 30-day supply of Tier Three drugs

•

0% Coinsurance after Deductible for up to a thirty (30) day supply of Tier Four drugs

•

Mail order 0% Coinsurance after Deductible for up to a 90-day supply.

Service Charge for Brand-Name Drugs When a Generic is Available If a Brand-name Drug is dispensed when a Generic equivalent that is subject to a Maximum Allowable Cost is available, the Member pays the Generic Copayment plus a Service Charge. A Service Charge is equal to the difference between the cost of the Brand-name drug and the cost of the Generic substitute, reflected by the Maximum Allowable cost. The Member pays a Service Charge whether he or she chooses to receive the name drug or the Prescriber requests that the Brand-name drug be dispensed when a Generic equivalent is available. (MAC A)

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Plan Code: 3000A-10 PPO INDIVIDUAL HDHP/HSA PLAN

PHI MO INDIV SCH (01/09) 6

RIDERS

NON-NETWORK

The greater of 50% Coinsurance of the retail cost of a Prescription Drug or the Network Copayment/Coinsurance including any applicable Service Chargefor up to a 30-day supply per Prescription Order or Refill.

PLAN OPTIONS

HSA/HDHP Amendment Eligible Subscribers and Dependents who qualify for a Health Savings Account (HSA) will have High Deductible Health Plan (HDHP) Benefits as outlined in this Schedule of Coverage and Benefits, and the HSA Amendment.

You may use Your HSA account to pay for non-qualified medical expenses, although withdrawals for such expenses are subject to federal, state, and local taxes, as applicable, and in most cases, a penalty tax. Any unused balance in your account at Year-end is carried forward to the next Calendar Year. You are required both to determine whether withdrawals are used for qualified medical purposes and to report on Your annual tax return the amount withdrawn that is used for qualified medical expenses. Neither Mercy Health Plans nor its HSA banking partner will monitor this. Be sure to keep records (for example, receipts) so that You can prove to the IRS that the withdrawals are for qualified medical expenses that were not otherwise reimbursed. For examples of qualified medical expenses, see Your HSA Amendment.

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Mercy Health Plans

AMENDMENT

To the 2008 and 2009

Individual Schedule of Coverage and Benefits:

PHI MO INDIV SCH (01/09)

PHI MO INDIV SCH v.2 (01/08)

This Amendment describes certain changes in your Policy. Except as modified or superceded by the coverage

provided under this Amendment, all other terms, conditions, exclusions in the Certificate of Coverage and Schedule

of Coverage and Benefits remain unchanged and in full force and effect.

I. The Schedule of Coverage and Benefits listed above are amended by -

Deleting

these benefits below in their entirety and

replacing

as follows:

SERVICES

MEMBER RESPONSIBILITY

Durable Medical Equipment (DME) and Medical Supplies

Eye Examinations (Routine Only)

Expenses for one (1) routine eye exam each Calendar Year by an

Ophthalmologist or Optometrist.

Network Providers:

0% Coinsurance after Deductible

Non-Network Providers:

25% Coinsurance after Deductible

Neuropsychological Testing

Covered only for an individual with cognitive impairment due to medical or

psychiatric conditions, and who meet certain conditions as described in the

Certificate of Coverage.

Network Providers:

0% Coinsurance after Deductible

Non-Network Providers:

25% Coinsurance after Deductible

Orthotics

See Health Reform Amendment to the

2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND 5-10)

Outpatient Diagnostics

Covered Health Services received on an outpatient basis at a Physician’s

office, Hospital or Alternate Facility include:

Laboratory services

X-Ray/Imaging

Other diagnostic & therapeutic services

MRA

MRI

CT Scan

PET Scan

Nuclear Cardiology Imaging studies

Outpatient diagnostics received in the locations listed above will incur the

applicable outpatient diagnostic Copayment or Deductible and Coinsurance,

in addition to any cost-sharing for the Physician’s office visit, regardless of

whether other health services are received. Regardless of the place where

these services are performed, the cost-sharing for outpatient diagnostics will

Laboratory services:

Network Providers:

0% Coinsurance after Deductible

Non-Network Providers:

25% Coinsurance after Deductible

X-ray/Imaging:

Network Providers:

0% Coinsurance after Deductible

Non-Network Providers:

25% Coinsurance after Deductible

Other diagnostic/therapeutic

services:

Network Providers

0% Coinsurance after Deductible

- Prior Authorization required.

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SERVICES

MEMBER RESPONSIBILITY

apply.

A list of diagnostic/imaging services requiring Prior Authorization can be

obtained at

www.mercyhealthplans.com

or by calling Our Customer Contact

Center at the number listed on Your ID card.

Non-Network Providers:

25% Coinsurance after Deductible

MRA, MRI, CT Scan, PET Scan, and

Nuclear Cardiology Imaging Studies:

Network Providers:

0% Coinsurance after Deductible

Non-Network Providers:

25% Coinsurance after Deductible

Outpatient Surgery/ Hospital Procedures

Coverage includes surgical services and Hospital procedures received on an

outpatient basis at a Physician’s office, Hospital or Alternate Facility.

Outpatient surgery/procedures received in these locations will incur the

applicable Copayment or Deductible and Coinsurance, in addition to any

cost-sharing for the Physician’s office visit, regardless of whether other

health services are received.

Regardless of the place where these services are performed, the cost-sharing

for outpatient surgery will apply.

A list of outpatient surgical and hospital procedures requiring Prior

Authorization can be obtained at

www.mercyhealthplans.com

or by calling

Our Customer Contact Center at the number listed on Your ID card.

Surgical Implants

Implants for cosmetic or psychological reasons are excluded; see

Section 12, L. in Your Policy.

Outpatient Surgery/ Hospital

Procedures:

Network Providers:

0% Coinsurance after Deductible per

outpatient surgery or procedure.

Non-Network Providers:

25% Coinsurance after Deductible

per outpatient surgery or procedure.

Surgical Implants:

Network Providers:

Copayment/Coinsurance consistent

with type of service received.

0% Coinsurance after Deductible

25% Coinsurance after Deductible

Preventive Health Screenings ─ Routine Only

.

Prosthetic Devices

See Health Reform Amendment to the

2008 and 2009 Individual Schedule of Coverage and Benefits. (PHI MO/INDIV AMEND 5-10)

Rehabilitation Services

Outpatient Rehabilitation Therapy

Any combination of Network and Non-Network Benefits is limited as

follows:

Limited up to 60combined visits per Calendar Year for

Physical, Occupational and Speech Therapy.

36 visits of Pulmonary Rehabilitation therapy within a

12-week period per Calendar Year.

36 visits of Cardiac Rehabilitation therapy within a 12-week

period per Calendar Year.

Inpatient Rehabilitation Services

Any combination of Network and Non-Network Benefits is limited up

to a maximum of 60 days per Calendar Year.

Outpatient Rehabilitation Therapy PT/OT/ST:

Network Providers:

0% Coinsurance after Deductible

25% Coinsurance after Deductible

Pulmonary Rehabilitation:

Network Providers Network Providers:

0% Coinsurance after Deductible

25% Coinsurance after Deductible

Cardiac Rehabilitation:

Network Providers:

- Prior Authorization required.

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SERVICES

MEMBER RESPONSIBILITY

0% Coinsurance after Deductible

25% Coinsurance after Deductible

Inpatient Rehabilitation Services: Network Providers:

0% Coinsurance after Deductible

25% Coinsurance after Deductible

Deleting

the Birth Control Services section in its entirety and

replacing

with the following:

RIDERS

Birth Control Services

Required only if Prescription Drug

Services covered.

Contraceptives (oral, topical, injectable), intrauterine devices (IUDs),

and insertion and routine removal of implantable contraceptives no more

than once every three (3) Rolling Years, unless Medically Necessary.

II. The Schedules of Coverage and Benefits listed above are amended by

Deleting The First Steps – Infant & Toddler Early Intervention Program

benefit

in its entirety. This

is not a covered benefit.

- Prior Authorization required.

PHI MO/INDIV AMEND3-09

3 Schedule 2009

Charles S. Gilham, Vice-President

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PLAN #: 3000A-10, 5000A-10

- Prior Authorization required.

Prior Authorization can be found at www.mercyhealthplans.com, or by calling Our Customer Contact Center at the number listed on Your ID card.

PHI MO/INDIV AMEND5-10

1 Mercy Health Plans

HEALTH REFORM AMENDMENT

To the 2008 and 2009

Individual Schedule of Coverage and Benefits:

PHI MO INDIV SCH (01/09)

PHI MO INDIV SCH v.2 (01/08)

This Amendment describes certain changes in your Policy. Except as modified or superceded by the coverage

provided under this Amendment, all other terms, conditions, exclusions in the Individual Comprehensive Health

Insurance Policies and Schedule of Coverage and Benefits remain unchanged and in full force and effect.

The Schedule of Coverage and Benefits listed above are amended by deleting

the benefits below in their entirety

and

replacing

as follows:

SERVICES

MEMBER RESPONSIBILITY

Durable Medical Equipment (DME) and Medical Supplies

Standard Basic Hospital-type medical Equipment (and its associated supplies) that meets the following criteria in addition to those described in our Certificate of Coverage:

Ordered or provided by a Physician for outpatient use; Used for medical purposes;

Not consumable or disposable; and

Not of use to a person in the absence of a disease or disability. Durable Medical Equipment in excess of $1,000.00 (either purchase price or cumulative rental of a single item) must be approved in advance by the Plan. The following Medical Supplies are covered:

Diabetic supplies (see Diabetes Services above); Standard ostomy supplies;

Catheters (urinary and respiratory) and associated supplies such as drainage bags and irrigation kits;

Sterile surgical wound supplies;

Jobst stockings or other support hose ordered by a physician and determined to be Medically Necessary, but only two (2) support stockings per Calendar Year are covered.

Some DME and medical supply services require Prior Authorization, including DME and medical supplies that cost more than $1,000 (either purchase price or cumulative rental of a single item). A list of services requiring Prior Authorization can be obtained at www.mercyhealthplans.com or by calling Our Customer Contact Center at the number listed on Your ID card. Unless we pre-approve the services requiring Prior Authorization, or services that are over $1,000, Network and Non-Network Benefits will be reduced by 100% of the Eligible Expenses.

Network Providers:

0% Coinsurance after Deductible Non-Network Providers:

Human Leukocyte Antigen Testing - For bone marrow transplantation donor One (1) test per lifetime for bone marrow transplantation donor. Lab Benefit will apply to testing for all other purposes.

Network Providers:

0% Coinsurance after deductible Non-Network Providers: 25% Coinsurance after deductible Immunizations (Routine Only)

Routine immunizations for children and adults as recommended by the Department of Health and Senior Services and Federal law. Applicable cost-share for office visit(s) will apply for all other medical services besides immunization that are received in the same office visit.

Network Providers:

No Copayment and no Deductible Non-Network Providers:

No Copayment and no Deductible

Orthotics

Covered orthotic equipment is the Standard Basic Equipment necessary to continue

Network Providers:

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PLAN #: 3000A-10, 5000A-10

Prior Authorization can be found at www.mercyhealthplans.com, or by calling Our Customer Contact Center at the number listed on Your ID card.

PHI MO/INDIV AMEND5-10

2 SERVICES

MEMBER RESPONSIBILITY

the Instrumental Activities of Daily Living (IADL). The following items are covered when ordered and provided by a Participating Physician and obtained from a Participating Orthotic Provider:

Braces/support including necessary adjustments to shoes to accommodate braces. Braces that stabilize an Injured body part are considered Durable Medical Equipment and are a Covered Health Service

Trusses

Splints

Collars

Foot orthotics are a covered treatment only for neuropathy causing loss of protective reflexes, or severe vascular insufficiency due to diabetes, or vascular disease.

Any combination of Network and Non-Network Benefits for orthotic devices is limited to $5,000 per Calendar Year.

Some orthotic devices require Prior Authorization, including orthotics in excess of $1,000.00. A list of services requiring Prior Authorization can be obtained at www.mercyhealthplans.com or by calling Our Customer Contact Center at the number listed on Your ID card. Unless we pre-approve the services requiring Prior Authorization, or services that are over $1,000, Network and Non-Network Benefits will be reduced by 100% of the Eligible Expenses.

Osteoporosis Services/Bone Mineral Density (BMD) Testing

Preventive Health Screening for women according to the USPSTF guidelines and Federal law.

A list of osteoporosis services requiring Prior Authorization can be obtained at www.mercyhealthplans.com or by calling Our Customer Contact Center at the number listed on Your ID card.

Network Providers: Facility: No Copayment No Deductible or Coinsurance Professional Fees: No Copayment No Deductible or Coinsurance Office Visit: No Copayment No Deductible or Coinsurance Non-Network Providers:

25% Coinsurance after Deductible Preventive Health Screenings ─ Routine Only

Preventive Health Screenings in accordance with the American Cancer Society guidelines, Federal law and additional preventive Benefits provided by Mercy Health Plans. The Plan pays 100% for these Preventive Health Screenings only when you use Network providers. Deductible and Coinsurance will apply to services received from Non-Network Providers.

Services may be performed in a Physician’s Office or an Outpatient Facility and may incur both a professional fee and/or outpatient facility charges. Preventive Health Screenings include, but are not limited to, the services listed below. Any health screenings not listed here, or not required by Federal law, will be paid consistent with other services under the health benefit plan.

These Preventive Health Screenings are limited to one (1) routine test of each of the following every Calendar Year, unless otherwise indicated:

Cholesterol Tests Colon Screening:

Fecal Occult Blood Test

Colonoscopy – one (1) routine screening every ten (10) Rolling Years starting at age 50

Double-contrast Barium Enema – one (1) routine screening every

Cholesterol Tests: Network Providers: No Copayment

No Deductible or Coinsurance Non-Network Providers:

25% Coinsurance after Deductible Colon Screening(Fecal Occult Blood, Colonoscopy, Double-contrast Barium Enema, and Flexible Sigmoidoscopy): Network Providers:

No Copayment

25% Coinsurance after Deductible Mammography:

Network Providers: No Copayment

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PLAN #: 3000A-10, 5000A-10

Prior Authorization can be found at www.mercyhealthplans.com

SERVICES

MEMBER RESPONSIBILITY

five (5) Rolling Years starting at age 50

Flexible Sigmoidoscopy – one (1) routine screening every five (5) Rolling Years starting at age 50

Mammography starting at age 35 and older Pap Test

Pelvic Exam Prostate Exam

PSA test starting at age 40

Preventive Health Screening in a Physician’s office including one (1) annual physical exam per Calendar Year for adults, and periodic visits for well-baby and well-child care as follows:

10 visits, birth to 24 months

1 visit per Calendar Year for ages 2 – 18 years

Note:

All other Covered Services in a physician’s office will be

covered under Physician’s Office Services.

25% Coinsurance after Deductible Pap/Pelvic:

25% Coinsurance after Deductible Prostate Exam:

25% Coinsurance after Deductible PSA Test:

25% Coinsurance after Deductible Annual Physical Exam and well-child visits in a Physician’s office: Network Providers: No Copayment

25% Coinsurance after Deductible Prosthetic Devices

Covered prosthetic equipment is the standard, basic equipment necessary to continue average daily activities. Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998 is also covered. No time limit will be imposed for the receipt of breast prosthesis and related reconstructive breast surgery following a mastectomy. Coverage also includes post-mastectomy brassiere. Some prosthetic services require Prior Authorization, including prosthetics that cost more than $1,000. A list of services requiring Prior Authorization can be obtained at www.mercyhealthplans.com or by calling Our Customer Contact Center at the number listed on Your ID card. Unless we pre-approve the services requiring Prior Authorization, or services that are over $1,000, Network and Non-Network Benefits will be reduced by 100% of the Eligible Expenses.

Network Providers:

0% Coinsurance after Deductible Non-Network Providers:

Charles S. Gilham, Secretary

Mercy Health Plans

, or by calling Our Customer Contact Center at the number listed on Your ID card.

PLAN CODE: 3000A-10 MERCY HEALTH PLANS SCHEDULE OF COVERAGE AND BENEFITS