Summary Plan Description Aim Medical Trust - City of West Lafayette Plan H Effective January 1, 2020 Group Number 903864 AIM MEDICAL TRUST MEDICAL PLAN H TABLE OF CONTENTS SECTION 1 - WELCOME ................................................................................................................. 1 SECTION 2 - INTRODUCTION ......................................................................................................... 3 Eligibility ....................................................................................................................................... 3 Cost of Coverage ......................................................................................................................... 4 How to Enroll .............................................................................................................................. 4 When Coverage Begins ............................................................................................................... 5 Changing Your Coverage ............................................................................................................ 5 SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 7 Network and Non-Network Benefits ....................................................................................... 7 Eligible Expenses ......................................................................................................................... 8 Designated Provider and Other Providers ............................................................................. 10 Annual Deductible ..................................................................................................................... 10 Coinsurance ................................................................................................................................ 11 Out-of-Pocket Maximum ......................................................................................................... 11 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION ......................... 13 Care Management ...................................................................................................................... 13 Prior Authorization.................................................................................................................... 14 Special Note Regarding Medicare ............................................................................................ 15 SECTION 5 - PLAN HIGHLIGHTS ................................................................................................. 16 SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 27 Autism Spectrum Disorder ....................................................................................................... 27 Acupuncture Services ................................................................................................................ 28 Ambulance Services ................................................................................................................... 28 Anesthesia/Hospital Coverage for Dental Care.................................................................... 29 Cancer Resource Services (CRS) ............................................................................................. 29 Cellular and Gene Therapy ....................................................................................................... 30 Clinical Trials .............................................................................................................................. 30 Congenital Heart Disease (CHD) Surgeries ........................................................................... 32 i TABLE OF CONTENTS AIM MEDICAL TRUST MEDICAL PLAN H Dental Services - Accident Only .............................................................................................. 33 Diabetes Services ....................................................................................................................... 34 Durable Medical Equipment (DME) ...................................................................................... 35 Emergency Health Services - Outpatient ............................................................................... 37 Family Planning .......................................................................................................................... 37 Gender Dysphoria ..................................................................................................................... 37 Hearing Aids ............................................................................................................................... 39 Home Health Care ..................................................................................................................... 40 Hospice Care .............................................................................................................................. 40 Hospital - Inpatient Stay ........................................................................................................... 41 Inherited Metabolic Disease Treatment ................................................................................. 41 Kidney Resource Services (KRS) ............................................................................................. 42 Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 43 Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient................................................................................................................................. 43 Mental Health Services .............................................................................................................. 44 Neurobiological Disorders - Autism Spectrum Disorders Services ................................... 45 Nutritional Counseling .............................................................................................................. 46 Orthotic Devices and Prosthetic Devices - Artificial Arms, Legs, Feet and Hands ........ 47 Ostomy Supplies ........................................................................................................................ 48 Pharmaceutical Products - Outpatient .................................................................................... 48 Physician Fees for Surgical and Medical Services ................................................................. 49 Physician's Office Services - Sickness and Injury .................................................................. 49 Podiatry ....................................................................................................................................... 49 Pregnancy - Maternity Services ................................................................................................ 49 Preventive Care Services ........................................................................................................... 50 Prosthetic Devices ..................................................................................................................... 51 Reconstructive Procedures ....................................................................................................... 52 Rehabilitation Services - Outpatient Therapy and Manipulative Treatment ..................... 54 Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 56 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 56 Substance-Related and Addictive Disorders Services........................................................... 57 Surgery - Outpatient .................................................................................................................. 58 ii TABLE OF CONTENTS AIM MEDICAL TRUST MEDICAL PLAN H Temporomandibular Joint (TMJ) Services ............................................................................. 59 Therapeutic Treatments - Outpatient ..................................................................................... 60 Transplantation Services ........................................................................................................... 60 Travel and Lodging .................................................................................................................... 61 Urgent Care Center Services .................................................................................................... 63 Virtual Visits ............................................................................................................................... 63 Vision Examinations ................................................................................................................. 63 Wigs ............................................................................................................................................. 64 SECTION 7 - CLINICAL PROGRAMS AND RESOURCES ........................................................... 65 Consumer Solutions and Self-Service Tools .......................................................................... 65 Disease and Condition Management Services ....................................................................... 68 Wellness Programs ....................................................................................................................