PPO PLAN (CONTINUED) FMOLHS NETWORK PREFERRED PROVIDER NON-PREFERRED OUT-OF-NETWORK (TIER 1) NETWORK (TIER 2) PROVIDER (TIER 3) OTHER SERVICES OCCUPATIONAL THERAPY 80% coverage after deductible; 70% coverage after deductible 60% coverage after deductible PHYSICAL THERAPY No coverage SPEECH THERAPY Maximum of 120 visits per year (and maximum of 20 visits per week) combined with Occupational, Physical, and Speech Therapy 70% coverage after deductible; 80% coverage after deductible; 60% coverage after deductible; APPLIED BEHAVIOR ANALYSIS (ABA) No coverage max 20 hours per week annually max 20 hours per week annually max 20 hours per week annually SPECIFIC GENETIC TESTING 80%; drawn/ordered by (MUST SATISFY MEDICALLY NECESSARY No coverage No coverage No coverage CRITERIA) FMOLHS Geneticist SMOKING CESSATION AID 100% coverage of screening for tobacco use and two tobacco cessation attempts per year which includes four tobacco cessation counseling sessions of at least 10 minutes each without prior authorization and No coverage Smoking cessation is available through the 90 day supply of Smoking Cessation Aids when prescribed by a health care provider without prior prescription bene昀椀t program authorization DURABLE MEDICAL EQUIPMENT (DME) 80% coverage after deductible; 70% coverage after deductible 60% coverage after deductible No coverage 80% coverage after deductible; 70% coverage after deductible; 60% coverage after deductible; INSULIN PUMP No coverage limited to 1 per 5 years limited to 1 per 5 years limited to 1 per 5 years ORTHOTICS AND PROSTHETICS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible GENERIC DIABETES 100% coverage of Generic Diabetes Prescription Medications PRESCRIPTION MEDICATIONS No coverage No coverage AND PREFERRED SUPPLIES and Preferred Supplies through the pharmacy bene昀椀t MENTAL/NERVOUS AND SUBSTANCE ABUSE INPATIENT Including Partial Hospitalization (PHP), 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible Intensive Outpatient Program (IOP) and Residential OFFICE VISIT ONLY $5 copay $30 copay 60% coverage after deductible 40% coverage after deductible OTHER OUTPATIENT SERVICES 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible PREGNANCY CARE AND DELIVERY LABOR & DELIVERY AND ASSOCIATED CHARGES 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible 80% coverage after deductible; 70% coverage after deductible; 60% coverage after deductible; MATERNAL/FETAL ULTRASOUND other than included in other than included in other than included in 40% coverage after deductible pre-natal care pre-natal care pre-natal care IN NETWORK BREAST PUMP AND LACTATION COUNSELING 100% coverage 100% coverage 100% coverage No coverage THROUGH HEALTHY LIVES One time $50 copay applies to routine OB visits, initial routine labs and PRE-NATAL CARE 40% coverage after deductible one ultrasound per term pregnancy. 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. 20