PPO2500 Medical Benefit Summary - WVP Health Authority

1 01012013_PPO2500 This is a Benefit Summary only. It is not intended to govern the Plan. If any discrepancies arise; the Plan document will govern. Errors and omissions are not intentional. A complete list of benefits and the limitations and exclusions that apply to them will be specified in the Summary Plan Description. PPO2500 PLAN Network providers have contracted with the Trust to provide services and supplies to enrolled members. They may not bill you for amounts in excess of your deductible, copayment, or coinsurance.

2 Non Network Providers have no such arrangement and our reimbursement is based on Usual Customary and Reasonable Charges (UCR). Non Network Providers may bill you for amounts in excess of your deductible, copayment, or coinsurance. Network Providers Non Network Providers Deductible Per Calendar Year $2,500 single coverage $5,000 family coverage Out of Pocket Maximum (includes deductible and coinsurance) Per Calendar Year $5,000 single coverage $10,000 family coverage COVERED CHARGES Preventive Care Services Well baby care 100% deductible waived 60% deductible waived Immunizations 100% deductible waived 60% deductible waived Routine Physicals 100% deductible waived 60% deductible waived Routine gynecological exams 100% deductible waived 60% deductible waived Routine colonoscopies 100% deductible waived 60% deductible waived COVERED CHARGES Deductible Applies to all services listed below Professional Services Office visits for illness

3 Or injury 80% 60% Maternity care 80% 60% Diagnostic lab & radiology 80% 60% MRI, CAT scan, PET scan 80% 60% Urgent Care 80% 60% Hospital Services Inpatient services 80% 60% Physicians Visits & Consultations in hospital 80% 60% Outpatient surgery 80% 60% Emergency room * 80% 80% Skilled nursing facility (20 day calendar year maximum per condition) 80% 60% Inpatient Rehabilitation 80% 60% Other Services Jaw Joint/TMJ ($1,000 calendar year maximum) 80% 60% Infertility Treatment *($1,000 calendar year maximum) 50% 50% Durable Medical Equipment (DME) 80% 60% Home Health Care (60 consecutive days maximum per condition) 80% 60% Ambulance Services 80% 80% Outpatient Private Duty Nursing (Limited to 60 visits per calendar year) 80% 60% 01012013_PPO2500 This is a Benefit Summary only.

4 It is not intended to govern the Plan. If any discrepancies arise; the Plan document will govern. Errors and omissions are not intentional. A complete list of benefits and the limitations and exclusions that apply to them will be specified in the Summary Plan Description. Hospice Care ($15,000 inpatient and outpatient lifetime maximum) 80% 60% Occupational, Speech and Physical Therapy (Limited to 30 combined sessions per calendar year) 80% 60% Chiropractic Services (Limited to $1,000 per person per calendar year) 80% 60% Mental Health /Chemical Dependency Office Visits 80% 60% Inpatient Care 80% 60% Residential programs 80% 60% *For true Medical emergencies, non participating providers are paid at the participating provider level.

5 Prescription Drug Plan Deductible Per Calendar Year Calculated together with your Medical deductible Out of Pocket Maximum Per Calendar Year Calculated together with your Medical out of pocket maximum Prescription Medications From a Pharmacy or Mail Order Supplier Generic or brand name medications (90 day supply) 80% PPO Plan Limits Diabetes self education program One every five years, $300 maximum Benefit per program Women s Healthcare Services One per calendar year between the ages of 18 and 64 Frequency Limits for Mammograms One mammogram per calendar year regardless of age Well baby/child care Under age 2 Age 2 6 Age 7 18 Eight visits maximum One per calendar year One every two calendar years Routine Physicals Age 19 34 Age 35+ One every four calendar years One every two calendar years Infertility Treatment Includes care.

6 Supplies and services for diagnosis, prescription drugs for treatment and charges for surgical correction of physiological abnormalities of infertility. Transplant Donor Maximum $25,000 per covered transplant