PLAN LIMITATIONS & EXCLUSIONS GHC-SCW Individual Plans

This is an outline of the Limitations and Exclusions for the Group Health of South Central Wisconsin (GHC-SCW) group and individual health plans. It is designed for reference only. Consult the Policy, Policy Amendments, Certificate of Our plans are further organized into “Metals” based on the percentage of health care costs shared Coverage and Benefits Summary for a complete list of Limitations and Exclusions. The following services and expenses are between you and GHC-SCW. not covered, and no benefits will be payable unless stated otherwise for expenses arising from:

Medical care or services provided by a Complications, consultations, services Keratorefractive surgery specifically included under the Policy Platinum Plans GHC-SCW pays 90% of health Bronze Plans GHC-SCW pays 60% of health non-GHC-SCW Provider, whether or not and procedures related to a non-covered or Certificate of coverage), telephonic care costs; you pay 10%. Associated with the care costs; you pay 40%. Associated with the under contract with GHC-SCW. Using a non- procedure Surrogate maternity services and midwife mental health care therapy session, GHC-SCW Provider or an Out-of-Plan Provider services sexual dysfunction therapy, financial and highest monthly premiums and the lowest out of lowest monthly premiums and the highest out of is not covered and the Member will be Cosmetic services occupational counseling, and therapies Medical Supplies, including durable and financially responsible for full payment of care beyond the services specified in the Policy or Custodial care disposable medical equipment, supplies and pocket expenses. Includes Essential Health Benefits. pocket expenses. Includes Essential Health Benefits. and services unless: written approval for Out- Certificate of coverage prosthetic appliances not specifically covered of-Plan care and services has been obtained Dental services not specifically covered under under the Policy or Certificate of coverage Therapies for the diagnosis and treatment of from GHC-SCW’s Care Management the Policy or Certificate of coverage chronic brain injury, including augmentative Gold Plans 80% Catastrophic Plans Department prior to obtaining the medical Mental Health and Substance Use Disorder GHC-SCW pays of health care This plan includes all the communication devices, and speech therapy care or service; is for an Emergency Condition Developmental delay (unless specifically services beyond the services specified in the for the treatment of stuttering, developmental costs; you pay 20%. Associated with high monthly Essential Health Benefits, but is only available to or an Urgent Condition when the Member is included under the Policy or Certificate of Policy or Certificate of coverage outside of the GHC-SCW Service Area; or, the coverage) including: nonmedical services delay, mental retardation or cerebral palsy, premiums and low out of pocket expenses. Includes young adults 30 and under, or to people who plan provides for the use of non-GHC-SCW for the evaluation, diagnosis, testing or Coverage for medical problems which unless specifically included under the Policy Providers treatment of educational problems, behavior never would have occurred except through or Certificate of coverage Essential Health Benefits. qualify for a hardship exemption due to low income. modification or educational disorder services hospitalization, including but not limited to Third-party examinations Services that are not Medically Necessary, injuries or illnesses that could have been are experimental, investigative or for research Drug screening, except as specifically covered (This plan is only offered in the marketplace.) prevented such as certain infections, severe Tobacco cessation products, except as purposes under the Policy or Certificate of coverage bedsores, fractures, and medical errors specified in the Policy or Certificate of Silver Plans GHC-SCW pays 70% of health care coverage Billed amounts that are over and above the Electrolysis services Obesity-related services costs; you pay 30%. Associated with low monthly GHC-SCW Reasonable and Customary Fees Tongue thrust services or treatment and Charges for covered benefits Emergency Outpatient Services when a Personal comfort items premiums and high out of pocket expenses. Includes Member leaves the emergency room prior to Transplants, except for those specified in Items or services required as a result of war or seeing a physician Prescription drugs or contraceptive devices the Policy or Certificate of coverage and Essential Health Benefits. any act of war, insurrection, riot, terrorism, or unless specifically included under the Policy services, any organ or tissue which is sold sustained while performing military services End of Life Services not specifically included or Certificate of coverage under the Policy or Certificate of coverage rather than donated, involving non-human or Services provided at U.S. Government Health Private duty nursing services artificial organs and tissues, and human to Facilities Food/Infant Formula and enteral nutritional human organ or tissue transplant other than products (medical foods) Prolotherapy those specifically listed and specified within Services provided before the effective date the Policy or Certificate of coverage or after the termination date of the Policy or Functional capacity evaluations Scar revisions Terms to Know Certificate of coverage Transportation services and costs, except Gastro-intestinal surgical procedures for Sex change operations Medically Necessary ambulance services Co-Payment – A fixed amount (for example, $15) In-Network – The facilities, Providers, and Services related to an admission or purposes of weight loss Specialty medical care provided by a non- confinement which occurs prior to and Vocational Rehabilitation services you pay for a covered health care service. The suppliers your health insurer or plan has Growth Hormone for the treatment of GHC-SCW Provider, whether or not under continues on or after the Member’s effective idiopathic short stature contract with GHC-SCW, when the service Vision services, and eyewear for all date when GHC-SCW coverage replaces amount can vary by the type of covered health care contracted with to provide health care services. requested may be provided by a GHC-SCW Members (to include lenses, frames, contact other group coverage. Home modifications Specialty Provider lenses, contact lens prescriptions or contact service. Visit ghcscw.com and select “Find a Provider” to Services while incarcerated, except as lens fitting), unless specifically included under Housecleaning Sperm banking or egg harvesting specifically required by state or federal law the Policy or Certificate of coverage find In-Network facilities and Providers. Hospital services for a Skilled Nursing Facility Supportive care Workers’ Compensation items and services Deductible – The amount you owe for health care Charges for missed appointment(s) beyond the amount specified in the Policy or incidental to an injury or conditions covered Certificate of coverage Surgical Services and treatment to correct or Services for injuries incurred during the by any Workers’ Compensation law or services your health or plan covers before HMO plans emphasize high-quality, preventive reverse complications and/or dissatisfaction commission of a crime occupational disease law Hypnotherapy services resulting from surgery, cosmetic treatment, or your or plan begins to pay. For health care with a strong relationship with a Primary reconstruction when no functional impairment Bilateral Cochlear Implants and Bilateral Bone Insulin injection pens not included in the GHC Out-of-Area Dependents (who do not reside exists, as determined by GHC-SCW example, if your deductible is $1000, your plan Care Provider and access to area Specialists. We Anchored Hearing Aid (BAHA) devices formulary. in the Service Area) are only eligible for Out-of-Area Services as specified in the Tattoos: services for the removal of tattoos or won’t pay anything until you’ve met your $1000 recommend this plan for members that live in Dane Blood donor services Infertility services not specifically covered Policy or Certificate of coverage, unless the complications related to tattoos under the Policy or Certificate of coverage, plan provides for the use of non-GHC-SCW Common use supplies deductible for covered health care services subject to County, WI and surrounding communities. and services beyond the Benefit Maximum Transplant donor services when the recipient Providers Complementary Medicine services not specified in the Benefits Summary is not a current Member under this certificate. the deductible. The deductible may not apply to all specifically covered under the Policy or Certificate of coverage Recreational and Educational therapy, services. HSA plans are accounts created for individuals therapy for congenital conditions (unless who are covered under high-deductible health Maximum Out-of-pocket – The most you pay plans (HDHPs) to save for medical expenses that during a policy period (usually a year) before your HDHPs do not cover. Contributions are made into Important: This plan summary provides Prior Authorization means advance This Policy will become effective as of the We define a “grievance” as meaning health insurance or plan begins to pay 100% of the account by the individual or the individual’s only a general description of benefits authorization for specific medical services date stated in your letter of acceptance. dissatisfaction with the provision of services and limitations. You can find a detailed or treatment. Services requiring Prior Renewal periods of coverage for this Policy or claims practices or administration of a the allowed amount. This limit never includes your employer and are limited to a maximum amount description of coverage in the Individual Authorization are specified in the Covered are annually, and occur on January 1 for health plan. This grievance is generally Plan Certificate. Coverage is subject to all Health Services section of the Certificate and all policyholders. We will renew this Policy expressed to us in writing by a member or premium, balance-billed charges or health care your each year. the terms and conditions of the certificate in the Benefits Summary. Failure to obtain unless we discontinue offering this type of by a member’s representative. A member and any amendments. If there is ever a Prior Authorization may result in a reduction Individual Policy in Wisconsin. The Policy is may file a grievance with us by sending their health insurance or plan doesn’t cover. Some health discrepancy between this plan summary or declination of coverage. guaranteed renewable except for the reasons written grievance to: insurance or plans don’t count all of your and the Individual Certificate, the Individual stated in the Individual Certificate, Article II. Certificate has final authority. Premium Rates and Renewal Terms ATTN: Member Appeals Your premium is based on a number of Emergency Outpatient Care occurring GHC-SCW Member Services Department co-payments, deductibles, co-insurance payments, Benefit and Provider Information factors, including your age and the benefit at an Out-of-Network Provider or facility may P.O. Box 44971 out-of-network payments or other expenses toward The GHC-SCW Individual Certificate option you select. Premium rates may change be subject to applicable limitations to include Madison, WI 53744-4971 requires the use of In-Network Providers. from time to time. You must submit the initial reasonable and customary charges, medical this limit. or 2015, the new Maximum Out-of-pocket Benefits payments will be subject to the monthly premium, along with your completed necessity determination or other provisions, Dependent Children The GHC-SCW applicable Deductible, Co-insurance, annual application materials to us. All subsequent exclusions, or limitation of the policy. Individual Policy includes coverage for amounts are $6,600 (single) and $13,200 (family). Out-Of-Pocket Maximums, Co-payments, premium payments should be sent to us along eligible Dependent children through the Lifetime Maximum Benefits, Exclusions and with a copy of the premium invoice. This Grievance Procedure If a member has end of the month they turn age 26. There Limitations and other policy terms and Policy will remain in force and will renew for a question or concern that can’t be resolved may be tax consequences to individuals conditions. A member’s coverage depends future periods of coverage as long as you by our Member Services Department, he or who enroll dependents who do not meet on his or her eligibility under the terms and pay your premiums on time. We will notify she can file a written grievance detailing the the IRS definitions of dependents/spouses. conditions of the GHC-SCW certificate. you of a premium change at least 30 days reason(s) for disagreeing with our benefit or Individuals may want to consult with a tax prior to your renewal date. We will provide claim payment decision. advisor prior to enrolling Dependents for this a 60-day notice of any premium increase of coverage. 25% or more.

MK14-167-1(02/15)FL For a complete description of covered services, please see your Member Certificate, Benefits Summary and any Amendments to your Benefits Plan. If you have questions regarding INDIVIDUAL PLANS GHC-SCW Benefits, please call GHC-SCW Member Services at (608) 828-4853 or toll free at (800) 605-4327, press 0 and ask for Member Services.

Platinum 500 Platinum 1000 Gold 1000 Gold 2000 Gold 2000 Silver 2000 Silver 3500 Bronze 4000 Bronze 5000 Catastrophic Silver 30 Copay Deductible Benefit Arch Deductible Benefit Arch Deductible HSA Deductible Deductible HSA Deductible Deductible HSA 6,600 Deductible

$2,000 Per Single or $3,500 Per Single or $5,000 Per Single or $6,600 Per Single or $500 per Member or $1,000 per Member or $1,000 per Member or $2,000 per Member or $2,000 per Member or $2,000 per Member or $4,000 per Member or Policy Deductible $4,000 per Family $7,000 per Family $10,000 per Family $13,200 per Family $1,000 per Family $2,000 per Family $2,000 per Family $4,000 per Family $4,000 per Family $4,000 per Family $8,000 per Family (Medical and RX combined) (Medical and RX combined) (Medical and RX combined) (Medical and RX combined) Policy Co-Insurance 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 0% after Deductible 30% after Deductible 30% after Deductible 0% after Deductible 30% after Deductible 20% after Deductible 0% after Deductible

$1,000 per Member or $2,500 per Member or $3,000 per Member or $4,000 per Member or $2,000 per Single or $6,000 per Member or $6,000 per Member or $3,500 per Single or $6,600 per Member or $6,450 Per Single or $6,600 per Member or Maximum Out-of-Pocket (MOOP) $2,000 per Family $5,000 per Family $6,000 per Family $8,000 per Family $4,000 per Family $12,000 per Family $12,000 per Family $7,000 per Family $13,200 per Family $12,900 per Family $13,200 per Family Policy Lifetime Maximum No Limit, unless specified below No Limit, unless specified below No Limit, unless specified below No Limit, unless specified below Eligible Dependent children are covered until the Eligible Dependent children are covered until the Eligible Dependent children are covered until the Eligible Dependent children are covered until the Eligible dependents end of the month in which they turn 26. end of the month in which they turn 26. end of the month in which they turn 26. end of the month in which they turn 26.

Care Plus Package

Applies to Benefit Arch Plans Only Covered services exceeding $1,000 will be subject 100% coverage for 100% coverage for to the plan’s Annual Deductible and Co-insurance. the first $1,000 of the first $1,000 of Services which are eligible for the CARE Plus Package n/a n/a n/a n/a n/a n/a n/a n/a n/a covered services per covered services per include services for Primary/Specialy Care Office Visits, Member per PlanYear. Member per PlanYear. Chiropractic Care, X-Ray/Lab Services and Inpatient Hospital Services.

Clinic Services First 3 visits no charge, Office Visits, Urgent Care, Chiropractic Care $20 Co-Payment* 20% after Deductible $30 Co-Payment* 20% after Deductible 0% after Deductible $30 Co-Payment* 30% after Deductible 0% after Deductible $85 Co-Payment* 20% after Deductible then 0% after deductible (P) Preventive Health Examinations $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment

(P) Prenatal/Postnatal Maternity Care $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment

Specialty Care Office Visits $20 Co-Payment* 20% after Deductible $30 Co-payment* 20% after Deductible 0% after Deductible $30 Co-Payment* 30% after Deductible 0% after Deductible $85 Co-Payment* 20% after Deductible 0% after deductible 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 0% after Deductible 30% after Deductible 30% after Deductible 0% after Deductible 30% after Deductible 20% after Deductible 0% after deductible Speech, Occupational, Physical Therapy up to maximum up to maximum up to maximum up to maximum up to maximum up to maximum up to maximum up to maximum up to maximum up to maximum up to maximum Diagnostic X-ray and Lab Services (CT, PET, MRI Scans) 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 0% after Deductible 30% after Deductible 30% after Deductible 0% after Deductible 30% after Deductible 20% after Deductible 0% after deductible

(P) Vision Examinations One pair of Eyeglasses (GHC-SCW Select Frames and Basic Lenses) per $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment Calendar year for Members under age 19

Dental Services

Preventive Dental for Children under age 19. $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment Major Dental/Orthodontia for Children under age 19. The pediatric orthodontia benefits are subject to a 24-month waiting period.During the 24-month waiting period, the 50% after Deductible 50% after Deductible 50% after Deductible 50% after Deductible 0% after Deductible 50% after Deductible 50% after Deductible 0% after Deductible 50% after Deductible 20% after Deductible 0% after deductible member must be continuously enrolled in a GHC-SCW plan. $75 for initial visit of Acupuncture and Naturopathy $45 for one-hour personal sessions. Complementary Medicine $75 for initial visit of Acupuncture and Naturopathy $45 for one-hour personal sessions. For HSA Plans, co-payment applies after deductible. For HSA Plans, co-payment applies after deductible. Hospital Services

Inpatient Hospital Services (Including Facility Fees) 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 0% after Deductible 30% after Deductible 30% after Deductible 0% after Deductible 30% after Deductible 20% after Deductible 0% after deductible

Outpatient Surgery (Including Facility Fees) 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 0% after Deductible 30% after Deductible 30% after Deductible 0% after Deductible 30% after Deductible 20% after Deductible 0% after deductible

Emergency Room Visits $100 Co-payment $100 Co-payment $250 Co-payment $250 Co-payment 0% after Deductible $300 Co-payment $200 Co-payment 0% after Deductible $300 Co-payment 20% after Deductible 0% after deductible

Air/Ground Emergency Ambulance service $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment 0% after Deductible $0 Co-payment $0 Co-payment 0% after Deductible $0 Co-payment 20% after Deductible 0% after deductible

Outpatient Prescription Drugs (RX)

Tier 1 $10 Co-payment $10 Co-payment $20 Co-payment $20 Co-payment 0% after Deductible $30 Co-payment $30 Co-payment 0% after Deductible $50 Co-payment 20% after Deductible 0% after deductible

Tier 2 $30 Co-payment $30 Co-payment $40 Co-payment $40 Co-payment 0% after Deductible $60 Co-payment $60 Co-payment 0% after Deductible $150 Co-payment 20% after Deductible 0% after deductible

Tier 3 $60 Co-payment $60 Co-payment $80 Co-payment $80 Co-payment 0% after Deductible $120 Co-payment $120 Co-payment 0% after Deductible $250 Co-payment 20% after Deductible 0% after deductible

Tier 4 30% ($300 Maximum) 30% ($300 Maximum) 30% ($300 Maximum) 30% ($300 Maximum) 0% after Deductible 30% ($300 maximum) 30% ($300 maximum) 0% after Deductible 50% Co-payment 20% after Deductible 0% after deductible

Mental Health Services/Substance Use Disorder (SUD) Services

Outpatient - At GHC-SCW Clinics or Gateway Recovery $20 Co-Payment* 20% after Deductible $30 Co-Payment* 20% after Deductible 0% after Deductible $30 Co-Payment* 30% after Deductible 0% after Deductible $85 Co-Payment* 20% after Deductible 0% after deductible

Inpatient 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 0% after Deductible 30% after Deductible 30% after Deductible 0% after Deductible 30% after Deductible 20% after Deductible 0% after deductible

Transitional 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 0% after Deductible 30% after Deductible 30% after Deductible 0% after Deductible 30% after Deductible 20% after Deductible 0% after deductible

Please visit ghcscw.com to find the Summary of Benefits and Coverage (SBC) and *WAIVED FOR MEMBERS UNDER THE AGE 19. DO NOT CANCEL YOUR INSURANCE. COVERAGE IS NOT IN EFFECT UNTIL WRITTEN APPROVAL IS ISSUED. Glossary of Health Coverage and Medical Terms for the plans being quoted.