extensive physician network across new mexico & bordering states • Affordable Plans 37 new mexico hospitals INCLUDING THESE LOVELACE HOSPITALS: • more than 8,000 healthcare providers steps • Worldwide emergency coverage Lovelace Women’s Hospital Lovelace Medical Center healthy Only hospital in New Mexico dedicated State-of-the-art technology. to women’s health. State-of-the-heart care. Breast Care Center • New 64-slice CT Scanner We are committed to helping you take charge of your health by providing you with health-wise • High Risk Breast Cancer Program • Technologically advanced operating rooms • Rapid Results Assessment for same-day information and resources to access care. We encourage you to explore our no-cost HEALTHY mammogram results 24/7 Emergency Care • Breast care navigator to guide patients • Board-certified ED physicians through treatment • Fast-track unit for minor care needs Steps programs and make use of the services and education provided. • Dedicated Stroke Unit • Gold Plus Award in Stroke from health care that protects • Multi-disciplinary team of breast care specialists • 24/7 Neurology Coverage the American Heart Association’s • 12 private rooms Get with the Guidelines Program Family Birthing Center more than your employees. • Prenatal classes • Labor and Delivery Unit Dedicated Orthopedic Unit • Level III Neonatal Intensive Care Unit baby love s.t.o.p. healthy weight Gamma Knife Stop tobacco for optimal Help to achieve and maintain a 24/7 Emergency Care • Non-invasive brain surgery Health and support for a healthy pregnancy - 877.708.5777 prevention - 877.480.9368 healthy weight - 877.480.9368 New Natural Birthing Center • Multi-disciplinary team of breast care specialists • Water birthing Lovelace Regional Hospital- Lovelace Westside Hospital Roswell Loving care close to home. 24/7 EMERGENCY CARE healthy steps coaching healthy trails healthy steps personal FAMILY BIRTHING CENTER Help your kids grow up strong health assessment Lovelace Women’s Hospital Support about various treatment SURGICAL SERVICES and healthy - 877.480.9368 Assess your current health status - Family Birthing Center at options and disease management ORTHOPEDICS visit https://lovelace.abovehealth.com Westside coaching services for you if you online educational CARDIOLOGY Lovelace Women’s Hospital Birthing Center have a chronic condition like tools case management at Lovelace Westside Hospital now gives diabetes, asthma, heart disease or Tools to support and promote For members with complex health expectant mothers in Rio Rancho and the lung disease. - 800.390.9159 overall wellness - visit care needs - 800.808.7363 Westside access to birthing services closer to home. Heart Hospital of New Mexico at Lovelace Medical Center https://lovelace.abovehealth.com nurse advice & health The leader in heart care in New Mexico as Bariatric Program sUrgical Services behavioral health information line ranked by the Hospital Consumer outreach & education Radiology Services 24/7 Emergency Care Assessment of Healthcare Providers and Talk to a registered nurse about Systems (HCAHPS) survey released by the U.S. Community education programs your health issues or concerns - Department of Health and Human Services. for mental issues - 888.684.0461 877.725.2552 Lovelace Rehabilitation Hospital ext. 21765 Lovelace Rehabilitation Hospital is the only CARDIOLOGY VIEW CLAIMS ONLINE Care Concierge hospital in New Mexico accredited by the • Cardiac Catheterization Labs • Cardiothoracic Surgery Our website gives you easy access Commission on Accreditation of • Electrophysiology • Inpatient cardiac rehabilitation Lovelace’s Care Concierge team to your health plan information and Rehabilitation Facilities (CARF) in five • Valve repair and replacement • Stereotaxis Magnetic System for assists new members in their provides you with wellness tools, such programs: • TMR laser procedures heart rhythm disorders transition from non-contracted as our personal health coaches and • Stroke Specialty Program • Laser lead extraction providers and services to providers health assessments. It’s a convenient At Lovelace Health Plan, we believe that each encounter with a patient or health Dedicated • Spinal Cord System of Care and vendors contracted with and easy way to stay on top of all your Customer SURGICAL SERVICES care consumer offers an opportunity to make a difference in their health and well- • Inpatient Rehabilitation Programs Lovelace-505.506.6661 or our toll- health care coverage needs. Care/Claims • Vascular and endovascular • Valve repair/replacement • Brain Injury Inpatient Rehabilitation Programs free number at 800.808.7363 and For more information, please call • Open heart surgery • Bypass surgery • View and verify eligibility information being through our reputation for caring, customer service and positive outcomes. • Outpatient Medical Rehabilitation Programs ask to speak to a Care Concierge. • View claim information 24/7 EMERGENCY CARE We’re dedicated to keeping health care as simple as possible. We work closely with We provide a full continuum of inpatient and outpatient care, including • View explanation of benefits 727.5488 or physical therapy, occupational therapy, speech and language pathology, RADIOLOGY SERVICES physicians and our health care system to design programs and benefitsthat keep rehabilitation nursing and case management services. • CT Scan • Cardiac Echo • Ultrasound 877.232.1988 • Vascular Ultrasound • Nuclear Medicine • X-Ray plan members healthy and informed of their choices. Today, we serve more or email us at than 208,000 members in communities across New Mexico through health plans for [email protected] (responses within 24 hours) Dedicated individuals, employer groups, retirees and beneficiaries of government programs. se habla espa˜nol Lovelace Health Plan delivers Customer Care/Claims coverage network access under the MultiPlan For more information, please call wherever you go! PHCS Network 727.5488 or 877.232.1988 The MultiPlan PHCS Network offers access in all states to 568,000 ® ® health care professionals, over 4,100 hospitals and 63,000 ancillary or email us at [email protected] multiplan.com (responses within 24 hours) care facilities. No matter where you live, work, and seek health care, 800.950.7040 you have access to the largest independent network in the nation. se habla espa˜nol www.lovelacehealthplan.com/stateofnewmexico 2012 lovelace The following are the highlights of the Medical Plan administered by Lovelace Insurance Company Member’s Cost Covered for the State of New Mexico employees. These benefits are effective July 1, 2012 – June 30, 2013. Services Benefit/Service Description (Co-pay/Co-Insurance may be subject to Deductible) a plan to Any services received must be Medically Necessary and when required Benefit Certification must be Behavioral/ Outpatient services $30 office visit Co-pay obtained by your physician to be covered. The Specific terms of coverage, limitation and exclusions Mental Health Inpatient services $400 Co-pay per Admission 3 Partial hospitalization $200 Co-pay per Admission 3 are detailed in Sections 4, 5 and 6 of your Summary Plan Description (SPD) booklet. Residential Treatment Center $400 Co-pay per Admission (see SPD for limitations) 3 fit your budget Substance Outpatient services $30 office visit Co-pay Benefit Highlights Abuse Inpatient services $400 Co-pay per admission 3

Contract Year Member deductible Partial hospitalization $200 Co-pay per admission 3 Deductible1 • Single $150 • 2-Party $300 Intensive outpatient (non-Step Down) $100 Co-pay per admission • Family $450 Residential Treatment Center (see SPD for limitations) 3 $400 Co-pay per admission At Lovelace Health Plan, we are dedicated to keeping Contract Year Out-of-pocket maximum • Single $3,000 Out-of-Pocket Other Biofeedback (for specified medical conditions only) $30 Office visit Co-pay State of New Mexico employees happy and healthy. Maximum1 • 2-Party $6,000 • Family $9,000 Services Cardiac or pulmonary rehabilitation $30 Office visit Co-pay Lifetime Unlimited Maximum (Certain services are subject to Contract Year and/or lifetime maximums or are limited per condition.) Chemotherapy and/or radiation therapy No Co-pay

Chiropractic, Acupuncture, Naprapathic, Massage Therapy Why Choose Lovelace? Member’s Cost $30 Office visit Co-pay 4 ($1,500 combined Contract Year maximum) Covered Benefit/Service Description Services (Co-pay/Co-Insurance may be subject As a Lovelace Health Plan member & State of New Mexico to Deductible) Dental services (for specified medical conditions only) employee, you’ll have 3 Physician Office visit • Inpatient $400 Co-pay per admission • Services • Primary/OB/GYN Services $155 office visit Co-pay • Outpatient $30 Office visit Co-pay Access to a local customer care team through our dedicated • Specialty care (No referral required) $30 office visit Co-pay service unit. Dialysis No Co-pay Preventive services • Access to nearly 40 hospitals and more than 8,000 providers in New Mexico and its bordering states. • Adult wellness exam Durable Medical Equipment, orthotics, prosthetics and appliances 20% Coinsurance 3 • Well child care • An affordable, comprehensive plan that covers you and your • Vision screening (through age 17) Hearing Aids (to include repair, replacement, & associated testing) No Co-pay up to $2,500 per ear every family at home and while traveling. • Hearing screening (through age 25) No Co-pay 5 5 3 years • • Immunizations Emergency and urgent care coverage when traveling outside • Adult wellness Home health care $30 Physician Co-pay; no Co-pay for of New Mexico and outside of the country. • Laboratory and X-ray (associated with wellness exam) non-physician services • Access to a nationwide network through MultiPlan/PHCS to • Colonoscopy Hospice No Co-pay 3, 4 provide you and your family with access to providers outside of NM. Laboratory 10% Coinsurance • Bereavement counseling (limited to 3 sessions during the Hospice benefit period) X-ray 10% Coinsurance • Respite care (lifetime maximum of 2 sessions of up to 10 days for each Hospice benefit period) There’s More Allergy testing and treatment $30 office visit Co-pay Infertility related services (only limited services covered) Co-pay based on services • You do not have to select a primary care physician (PCP).

Medica l B enefit S u mm ary state of new Allergy injections by a nurse No Co-pay Simply use a contracted provider and the applicable co-pay Injectable drugs received in the office will apply. Allergy extract preparation No Co-pay • If billed in conjunction with an office visit Included in office visit Co-pay • • You do not need a referral to seek care with a specialist. Hospital Hospitalization (includes but not limited to: room and board, $400 Admission Co-pay 3 If provided by a nurse and no office visit is billed No Co-pay Services Inpatient Physician care, Physician visits, surgeon, x-ray, lab and Physical, occupational and speech therapy $30 office visit Co-pay 3 • Deductible does not apply when seeking care with your PCP anesthesiologist) and when seeking care for your annual Wellness exam. 10% Coinsurance Skilled nursing facility (Admission Co-pay waived if within 15 days) $400 Admission Co-pay 3 MRI/PET Scans/CT Scans (maximum $200 per test) Hospital Observation Services (no admission or surgical Sleep disorder studies $200 Co-pay • 3 procedure) Inpatient $400 Admission Co-pay • Sleep lab (outpatient facility) 10% Coinsurance Surgery/Outpatient Facility (applies to facility only) 10% Coinsurance Smoking cessation (does not include prescription drugs—see pharmacy vendor) 50% Coinsurance Maternity Physician/midwife services (delivery, prenatal/postnatal care) $15 Co-pay – initial visit only, m exico HM O Services all other visits no Co-pay Bariatric Surgery (for Morbid Obesity; must meet defined criteria in this SPD) • Inpatient $400 Admission Co-pay 3 Lovelace Global Emergency Complimentary No-COST CAR SEATS Home birth (services must be obtained by contracted provider) No Co-pay • Outpatient physician visit $30 Office visit Co-pay HealthLink Services Health Seminars 3 Moms-to-be get an infant car Hospital admission $400 Co-pay per pregnancy Transplants 3 Coverage for human organ transplants Co-pay based on place of service (refer to SPD for details on transplant coverage) Need help finding a Access a unique global As an LHP member, you seat by going to all of their Routine nursery care for newborns (unless baby is admitted No Co-pay emergency services program can attend complimentary doctor visits. Your baby can post delivery) doctor? Call Lovelace then receive a toddler car seat. Prescription from Assist America for you health seminars on the HealthLink at 898.3030 for and your covered latest health topics, such as Just take your baby to all well Emergency room visit $175 Co-pay 2 Administered by Medco. Call Medco at (800) 743-1720. Emergency Drugs help finding a doctor in the dependents. No matter cardiac surgery, peripheral child visits and get all shots by Urgent Care Center $50 Co-pay Services where you are in the world, vascular disease and 6 months of age. As your child Ambulance (waived if admitted) Albuquerque metro area 1. A maximum of three family members are required to satisfy the Family Deductible and Out of Pocket amount. LINC 289-0411 MCM20041 you’re covered for medical women’s health. grows, he or she can get a • that is right for you. Ground transportation $30 Co-pay per trip 2. The $175 emergency care is waived if an Admission results. Then, the Hospital Admission Co-pay applies. booster car seat after he or she • emergencies. Air ambulance $100 Co-pay per trip 3. Benefit Certification may be required or benefits may be denied. Please refer to specific benefit details in SPD for additional information on which services require Benefit Certification. gets all medical shots by age 2. 4. This benefit includes an annual maximum payment, annual visit limitation, lifetime visit limitation and/or lifetime maximum payment. 5. Not subject to the Deductible