Schedule of Benefits & Plan Design MEC HP3

1 Schedule of Benefits & Plan Design MEC HP3. The following table represents the type of medical services currently covered under the MEC HP3 Plan as well as the permitted interval and any requirements of such medical services. Note that some requirements may be defined by the benefit itself, such as cholesterol abnormalities screening: men 35 and older. Only men aged 35 or older may access such Benefits by fiat of the benefit itself. What You Will Pay Out-of-Network Medical Service Network Provider Limitations & Exceptions Provider (You (You will pay the will pay the least). most). Doctor's O ce $25 Member Copay Not Covered Limit of 3 doctor visits per plan year. Visit You may have to pay for services that aren't preventive. Ask your provider if Preventive and the services you need are preventive. 100% by Plan1 Not Covered Wellness Services Then check what your plan will pay for. See Schedule of Wellness and Preventive Services below. 1. No cost to member. Supplemental Hospital Benefit The following table represents the supplemental hospital benefit covered under the MEC HP3.

2 Supplemental Plan as well as the permitted interval and any requirements of such medical services. Plan Benefit Network Provider Out-of-Network Medical Service Limitations & Exceptions (You will pay the Provider (You will least) will pay the most). Hospitaliza on Limit to $1,000 per day; maximum of (Room and Board) 5 days per calendar year. Neonatal including MHSA $5,000 Supplemental Hospital Benefit intensive care (NICU) not covered. (Mental Health and Pre-existing conditions within past Substance Abuse) twelve months excluded. MEC HP3 is NOT a Major Medical Plan. This is an ancillary/supplementary, limited benefit plan offered by American Healthcare Benefits , 5015 Addison Circle, Box 338 Addison, Texas 75001. Not available in New Hampshire or Maine. For a full list of covered Benefits and restrictions, further documentation will be made available to you in a Summary Plan Description. Preventive Health Services: Limitations, Intervals, and Requirements The following table represents the type of medical services currently covered under the MEC.

3 HP3 Plan as well as the permitted interval and any requirements of such medical services. If a medical service does not have a specific interval under law or regulation, the interval for that medical service is once per year. Preventive Health Services Benefit Interval Description Abdominal aortic aneurysm By ultrasonography in men ages 65-75 years who 1 per lifetime screening have ever smoked Screenings for adults age 18 years or older for Alcohol misuse: alcohol misuse and provide persons engaged in 1. screening and counseling risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse Initiating low-dose aspirin use for the primary prevention of cardiovascular disease and colorectal cancer in adults aged 50 to 59 years who have a 10% or greater 10-year cardiovascular risk, are not at increased risk for Aspirin: preventive bleeding, have a life expectancy of at least 10. As prescribed years, and are willing to take low-dose aspirin medication daily for at least 10 years Use of low-dose aspirin (81 mg/d) after 12 weeks of gestation in pregnant women who are at high risk for preeclampsia Screening for asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16.

4 Bacteriuria screening 1. weeks' gestation or at the first prenatal visit, if later. Screening for high blood pressure in adults aged Blood pressure screening 1. 18 or older Screening to women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated BRCA risk assessment with an increased risk for potentially harmful and genetic 1 mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive counseling/testing screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. MEC HP3 is NOT a Major Medical Plan. This is an ancillary/supplementary, limited benefit plan offered by American Healthcare Benefits , 5015 Addison Circle, Box 338 Addison, Texas 75001. Not available in New Hampshire or Maine. For a full list of covered Benefits and restrictions, further documentation will be made available to you in a Summary Plan Description.

5 Risk-reducing medications, such as tamoxifen or Breast cancer preventive raloxifene for women who are at increased risk 1. medications for breast cancer and at low risk for adverse medication effects. Screening mammography for women aged 50 to 1 time every Breast cancer screening 74 years. Coverage limited to 2D mammograms 2 years only. Interventions during pregnancy and after birth to Breastfeeding interventions 2. support breastfeeding Cervical cancer screening: 1 time every Women age 21 to 65 years with cytology (Pap smear) 3 years Cervical cancer screening: with combination of cytology 1 time every Women age 30 to 65 years who want to lengthen and human papillomavirus 5 years the screening interval (HPV) testing Sexually active women age 24 and younger and Chlamydia screening 1. in older women who are at increased risk infection 1 time every Starting in adults at age 50 years and continuing Colorectal cancer screening 5 years until age 75 years Food and Drug Administration (FDA) approved Contraceptive methods and contraceptive methods, sterilization procedures, and As prescribed patient education and counseling for all women with counseling reproductive capacity, not including abortifacient drugs Application of fluoride varnish to the primary teeth Dental caries prevention: of all infants and children starting at the age of infants and children up to primary tooth eruption and prescription of oral 1.

6 Fluoride supplementation starting at age 6. age 5 years months for children whose water supply is fluoride deficient Screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. Depression screening 1. Screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. MEC HP3 is NOT a Major Medical Plan. This is an ancillary/supplementary, limited benefit plan offered by American Healthcare Benefits , 5015 Addison Circle, Box 338 Addison, Texas 75001. Not available in New Hampshire or Maine. For a full list of covered Benefits and restrictions, further documentation will be made available to you in a Summary Plan Description. Screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40.

7 To 70 years who are overweight or obese. Diabetes screening 1 Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. Falls prevention: exercise or Community-dwelling adults age 65 years and 1. physical therapy older who are at increased risk for falls Falls prevention: vitamin D Community-dwelling adults age 65 years and As prescribed supplementation older who are at increased risk for falls Daily supplement containing to mg (400 to Folic acid supplementation As purchased 800 g) of folic acid for all women planning or capable of pregnancy Gestational diabetes mellitus Asymptomatic pregnant women after 24 weeks 1. screening of gestation Gonorrhea prophylactic Prophylactic ocular topical medication for all 1 newborns for the prevention of gonococcal medication ophthalmia neonatorum Sexually active women age 24 years and Gonorrhea screening 1 younger and in older women who are at increased risk for infection Adults who are overweight or obese and have Healthy diet and physical additional cardiovascular disease (CVD) risk activity counseling to 1 factors to intensive behavioral counseling prevent cardiovascular interventions to promote a healthful diet and disease physical activity for CVD prevention.

8 Hemoglobinopathies 1 Screening for sickle cell disease in newborns screening Adolescents and adults at high risk for infection Hepatitis B screening 1. Pregnant women at their first prenatal visit Adolescents and adults at high risk for infection Hepatitis C virus (HCV). 1. infection screening Adults born between 1945 and 1965. Adolescents and adults aged 15 to 65 years. HIV screening 1 Younger adolescents and older adults who are at increased risk should also be screened. MEC HP3 is NOT a Major Medical Plan. This is an ancillary/supplementary, limited benefit plan offered by American Healthcare Benefits , 5015 Addison Circle, Box 338 Addison, Texas 75001. Not available in New Hampshire or Maine. For a full list of covered Benefits and restrictions, further documentation will be made available to you in a Summary Plan Description. Pregnant women including those who present in labor who are untested and whose HIV status is unknown Hypothyroidism screening Screening for congenital hypothyroidism in 1.

9 Newborns Women of childbearing age for intimate partner Intimate partner violence violence, such as domestic violence, and provide 1. screening or refer women who screen positive to intervention services. With low-dose computed tomography in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be Lung cancer screening 1. discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. To children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote Obesity screening and improvements in weight status. 1. counseling Screening all adults. Clinicians should offer or refer patients with a body mass index of 30 kg/m 2. or higher to intensive, multicomponent behavioral interventions In Women aged 65 years and older and in Osteoporosis screening younger women whose fracture risk is equal to or 1.

10 Greater than that of a 65-year-old white woman who has no additional risk factors Phenylketonuria screening 1 Screening for phenylketonuria in newborns Preeclampsia screening Pregnant women with blood pressure 1. measurements throughout pregnancy Rh incompatibility screening: Rh (D) blood typing and antibody testing for all 1 pregnant women during their first visit for first pregnancy visit pregnancy-related care Repeated Rh (D) antibody testing for all Rh incompatibility screening: unsensitized Rh (D)-negative women at 24 to 28. 1. 24 28 weeks' gestation weeks' gestation, unless the biological father is known to be Rh (D)-negative Intensive behavioral counseling for all sexually Sexually transmitted 1 active adolescents and for adults who are at infections counseling increased risk for sexually transmitted infections MEC HP3 is NOT a Major Medical Plan. This is an ancillary/supplementary, limited benefit plan offered by American Healthcare Benefits , 5015 Addison Circle, Box 338 Addison, Texas 75001.