HDHSA PLAN (CONTINUED) FMOLHS NETWORK PREFERRED PROVIDER NON-PREFERRED OUT-OF-NETWORK (TIER 1) NETWORK (TIER 2) PROVIDER (TIER 3) PREGNANCY CARE AND DELIVERY IN-NETWORK BREAST PUMP AND LACTATION COUNSELING 100% coverage 100% coverage 100% coverage No coverage THROUGH HEALTHY LIVES PRE-NATAL CARE 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible PREVENTATIVE CARE ROUTINE WELL ADULT CARE Generally limited to approved preventive or wellness services, which could include the 40% coverage 100% coverage 100% coverage 100% coverage following annual screenings depending on after deductible; Limited to one routine physical Limited to one routine physical Limited to one routine physical your age, gender, and health status: Lipid Limited to one routine physical examination annually and examination annually and examination annually and (Cholesterol), HGB A1C (Diabetes), Bone examination annually and Marrow Density Test, Mammogram, Pap approved wellness screenings approved wellness screenings approved wellness screenings approved wellness screenings Test, Fecal Occult Blood Test, Colonoscopy, annually. annually. annually. annually. Depression Screening, Obesity Screening and Counseling. *Please call the Claims Administrator to con昀椀rm coverage ADULT IMMUNIZATIONS Immunizations are subject to current CDC 100% coverage 100% coverage 100% coverage 40% coverage after deductible Recommendations which include age limitations ROUTINE WELL CHILD CARE Unlimited routine of昀椀ce visits through age two (2); annually ages three (3) up. Includes: 100% coverage 100% coverage 100% coverage 40% coverage after deductible of昀椀ce visits, routine physical examination and immunizations in accordance with CDC Guidelines and preventive care in accordance with federal guidelines. *FMOLHS follows federal guidelines for coverage of preventive wellness screenings. Note When you enroll in the HSA plan, PayFlex will provide you with a debit card that includes the FMOLHS annual contribution to help pay for eligible expenses. 23