GROUP COVERAGE - 2015 EPO FULL PAY - $10/$25/$50 RX. Covered Services Mercy System Providers Listed below is a partial outline of health services under the Policy. Annual Deductible: None See your Schedule of Benefits for applicable limits to these health services. If differences exist between this Summary of Benefits and Out of Pocket Max: $1,250 Single, $2,500 Family the Certificate of Coverage, the Certificate governs. All eligible benefits are based on medical necessity. Contact Customer Service Lifetime Max: Unlimited at 800-895-2421 with any question. Preventive Services Well Child Care to Six Years of Age Paid In Full Immunizations Paid In Full Preventive services as provided in the Federal Affordable Care Paid in Full Act. Refer to the following website to find all the services covered under this provision: www.healthcare.gov Physician Office Services All office visits & Physicals $15 Copay Eye Exam $15 Copay Hearing Exam $15 Copay Hearing Aids (See Certificate for child coverage) Limited to $500 per ear every 36 months Outpatient, Inpatient and Ambulatory Surgery Paid In Full Urgent Care $35 Copay Urgent Care Non Mercy Health System $50 Copay Emergency Room $100 Copay Emergency Ambulance (Ground or Air) Paid In Full X-Ray/Lab - Hospital & Physician Office Paid In Full Hospital Services - Inpatient/Outpatient Paid In Full Autism Intensive and Non-Intensive Services (Limited Benefits) Office Services $15 Copay Therapy Services Paid In Full Diagnostic Testing $15 Copay Diagnostic Evaluation Paid In Full Maternity Care Paid In Full Skilled Nursing Facility (Limited Benefits) Paid In Full Hospice Paid In Full Outpatient/Occupational and Speech Therapy Paid In Full Home Health Nursing Services Paid In Full Dental Surgery (Limited Benefits) Paid In Full Prosthetic and Durable Medical Equipment 80% Coverage Chiropractic $15 Copay Podiatry $15 Copay Treatment for Kidney (Limited to $30,000 per contract year) Paid In Full Transplants Paid In Full /Chemical Dependency Inpatient Treatment Paid In Full Transitional Treatment Paid In Full Outpatient Treatment $15 Copay TMJ Disorders (Limited Benefits) Office Visit $15 Copay Surgical Procedures Paid In Full Durable Medical Equipment 80% Coverage Prescription Drug (Limited to a 30 Day Supply per Copay) $10/$25/$50 Copay See your Prescription Drug Rider for Details

SUMMARY OF BENEFITS

This is a Benefit Summary only, and does not outline all benefits or exclusions in your Certificate of Coverage. Read the Certificate of Coverage or contact Customer Service at 1-800-895-2421 for more information or answers to specific questions.

Exclusive Provider Option (EPO) Copayments (Copay) This EPO has been developed to provide members quality A member’s fixed dollar amount of eligible expenses that you medical care that is also affordable. The provider network is must pay to the provider for services received. primarily made up with Mercy Health System physicians. General Exclusions Choosing an Primary Care Physician (PCP) • Services that are not medically necessary A PCP is a doctor who practices in one or more of these fields: • Cosmetic or elective orthodontic care, periodontic care or Family , Internal Medicine and Pediatrics. Each family general dental care member must select a doctor in one of these fields. Women may • Experimental procedures select an OB/GYN for routine gynecologic and obstetrical care, • Custodial care and convalescent care yet must still select a PCP for all other services. Please refer to • Hospice care provided outside the member’s home our Provider Directory for a complete list of participating PCPs. • Routine or preventative physicals when they are primarily at the request of, for the protection of, or to meet the Specialty Providers requirements of a party other than the member EPO has a specific list of Mercy Health System specialists to meet • Eyeglasses and contact lenses your needs of our members. You do not need a • Expenses incurred prior to membership, or services received referral from your PCP to see any of our EPO specialists, but we after the coverage or eligibility terminates encourage you to coordinate your specialty care with your PCP. • Holistic or homeopathic medicine

• Reversal of voluntary sterilization procedures and related No Claim Forms procedures When members use MercyCare providers, claim forms are not • Any surgical treatment or hospitalization for treatment of required and tedious paperwork is eliminated. Please make sure morbid obesity you show your identification card to the MercyCare provider so • programs that you are assured a paperless visit. Medical supplies and equipment for comfort, personal • and convenience such as but not limited to: air Participating Provider conditioners, humidifiers, equipment and Participating provider means a specific provider that is listed in self help devises not medical in nature the MercyCare provider directory as a participating provider in the EPO network. EPO providers are color coded in the • Benefits provided for or are payable by Workers’ directory. Compensation • Skin tag removal Emergency Care • Acupuncture Members who have a medical emergency within the MercyCare service area should, if possible, seek immediate attention at the nearest network provider. Members who have a medical emergency outside the MercyCare network should seek care at the nearest emergency facility. MercyCare should be notified within 48 hours, or as soon as possible.