Coventry Health Care of Florida, Inc. Schedule of Benefits HMO Focused Deductible Open Access Broward Sheriff’s Office - 2014 Referrals are not required for Covered Services Annual Hospital Deductible per calendar year: Individual / Family applies to all inpatient and outpatient services at hospital Maximum Copayment per calendar year: Individual / Family (includes copayments and deductible including prescription drug copayments) Maximum Lifetime Benefit Annual Pharmacy Deductible (per calendar year) Annual Pharmacy Benefit Maximum (per calendar year) Preventive Care Services Adult Wellness Care (includes annual physical exams, prostate cancer screening and colon cancer screening, eye exams, health education and counseling and immunizations, and annual well-woman exams, prenatal care, Pap smears, elective sterilization for women) Child Preventive Care (includes well child and well baby exams and immunizations) Routine mammography (based on established guidelines) Physician Services Primary Care Physician (PCP) office visits Specialist office visits (office visit includes lab tests, x-rays, hearing and vision screening and outpatient surgery) Non-Surgical Spine and Back services Limitation: 20 visits per calendar year Podiatry services Allergy injections at a PCP or Specialist office Maternity Postnatal Care  in a physician’s office  in a Sub-Specialty office Hospital Services $300 / $600 $2,000 / $4,000 Unlimited $0 Unlimited Member Responsibility Covered at 100%; No deductible Covered at 100%; No deductible Covered at 100%; No deductible Member Responsibility $15 copay $30 copay $15 PCP; $30 Specialist $15 PCP; $30 Specialist No copay after deductible One time $30 copay $30 copay Member Responsibility Inpatient hospital facility services (includes pre-admission testing, room and board, rehabilitative services, diagnostic tests, x-rays, operating & recovery room, intensive & special care units, general nursing care, anesthesia, prescribed drugs, radiation therapy & chemotherapy, surgeon services, anesthesiologist services, specialist consultation, physician visits, human organ transplants) Labor and delivery in a hospital or birthing center After Hospital Deductible: $100/day for the first 1-5 days Inpatient Neonatal Intensive Care Unit (NICU) (admission and subsequent inpatient care) After Hospital Deductible: $100/day for the first 1-5 days Outpatient Medical Services Outpatient Diagnostic Services  at Hospital  at an Outpatient Diagnostic Center  in a Physician’s office Outpatient Surgery (including physician and facility services)  at Hospital  at Ambulatory Surgical Center  in a Physician’s office Twenty three hour hospital admissions for medical observations, diagnostic or surgical stays Radiation and chemotherapy  at Hospital  at Freestanding Facility Mental Health, Alcohol & Substance Abuse Services Mental health care  Inpatient Treatment  Outpatient Treatment Alcohol and substance abuse care  Inpatient detoxification  Inpatient rehabilitation treatment  Outpatient rehabilitation treatment CHC.BSO.HMO.FDOA.SOB (1/14) After Hospital Deductible: $100/day for the first 1-5 days Member Responsibility After Hospital Deductible: $80 copay $30 copay No additional copay After Hospital Deductible: $150 copay $100 copay No additional copay After Hospital Deductible: No copay After Hospital Deductible: $30 copay $30 copay Member Responsibility After Hospital Deductible: $100/day for the first 1-5 days $30 copay After Hospital Deductible: $100/day for the first 1-2 days After Hospital Deductible: $100/day for the first 1-2 days $30 copay # 30415 Special Kinds of Care Emergency Services  In hospital emergency room In the service area ((waived if admitted)  In hospital emergency room Outside the service are (waived if admitted)  In a physician’s office  Ambulance service to hospital Urgent Care Center Convenience Care Clinic Services Outpatient physical, speech and occupational therapy (short and long term) Limitation: 60 visits per therapy type; per calendar year  at Hospital  at Freestanding Facility Outpatient cardiac and respiratory therapy  at Hospital  at Freestanding Facility Dialysis treatment (outpatient)  at Hospital  at Freestanding Facility Home Health Care Hospice Care Limitation: 210 days maximum lifetime benefit Skilled Nursing Facility Care Elective sterilization for Males  at Hospital  at Freestanding Facility Circumcision  in a Hospital prior to postnatal discharge  in a Physician’s office  in a Hospital after postnatal discharge Intrauterine Device (device, insertion, removal) Infertility related services; Limited to $15,000 Benefit Maximum  in an Office  in a Hospital Elective Abortions Durable medical equipment; other external orthotics and prosthetics Second medical and surgical opinion  Participating Provider  Non-Participating Provider Testing for Learning Disabilities (for children 5 years and older) Insulin Diabetic supplies (includes glucose monitors, test strips, lancets, etc.) Hearing Aids (other than cochlear) Services Provided by Rider or Endorsement Prescription Drugs (*)  At Participating Pharmacy per 30-day supply – Tier 4 Self-injectables: $250 per month out-of-pocket limit (except for diabetic supplies). Member Responsibility $200 copay $200 copay $15 PCP; $30 Specialist No copay $30 copay $15 copay After Hospital Deductible: $30 copay $30 copay After Hospital Deductible: $30 copay $30 copay After Hospital Deductible: $30 copay per treatment $30 copay per treatment No copay No copay $50/day for the first 1-2 days of each admission After Hospital Deductible: $200 copay $200 copay No additional copay $15 PCP; $30 Specialist Same as outpatient surgery Covered at 100%; No deductible $30 copay After Hospital Deductible: $100/day for the first 1-5 days Not covered No copay $15 PCP; $30 Specialist 40% of Allowed Amount $200 copay Applicable copay per prescription No copay; No deductible Not covered Member Responsibility Tier 1 - $10;MO: $20 Tier 2 - $25; MO: $50 Tier 3 - $50; MO: $100 Tier 4 – 20%; MO: not applicable $15 copay  Mail Order (MO) 90-day supply Vision care - at a participating Optometrist  Refractive eye exams Preventive Dental Care Refer to Dental Schedule of Benefits * If you or your physician requests a brand name medication when a generic is available, you must pay 100% of the difference in price between the generic and brand name medication, plus the applicable brand copayment. PCP referrals are not required to obtain Covered Services; however certain Covered Services require Prior Authorization. Please refer to the Certificate of Coverage for further detail on Prior Authorization requirements. Services must be rendered within the Coventry network. Coventry participating physicians and providers have contracted with Coventry to provide care to our members. This schedule is provided for information only; it does not contain complete details of the Plan which are available only in the Certificate of Coverage and it does not constitute an Agreement. This plan has exclusions and limitations and terms under which the plan may be continued in force or discontinued. CHC.BSO.HMO.FDOA.SOB (1/14) # 30415