Classic PPO $20/20%/40%/$1000 - Lovelace Health Plan

Classic PPO$20/20%/40%/$1,000 PlanLovelace Insurance Company provides the following benefits when Medically Necessary. This summary contains highlights onlyand is subject to change. Some benefits are subject to limitations, including, but not limited to visit or dollar maximums. Pleaserefer to the list of Limitations and Exclusions in this document. The specific terms of coverage and a detailed list of Limitationsand Exclusions are contained in the Evidence of Coverage (EOC) Handbook. Some services may not be covered Out-of-Network. Additionally, some services require a Prior Authorization. Unless otherwise noted, Co-Payment amounts are due at thetime of service. Services are paid according to the Tier level of the treating Provider. * If you have any questions about a specificservice or treatment, or would like to obtain an Evidence of Coverage (EOC) please contact the Lovelace Insurance CompanyCustomer Care Center at 505.727.5683, toll free 800.808.7363, TTY 800.659.8331 or www.lovelacehealthplan.com.CoveredServicesPre-existingConditionLimitationAnnualDeductible 1Annual Out-of-Pocket Limit 2DescriptionMember Deductibles,Co-payment & CoinsuranceIn-NetworkParticipatingProviderProviderOut-of-NetworkNon-ParticipatingA condition is pre-existing if it is a physical or mental condition for which medical advice,medication, diagnosis, care or treatment was sought or recommended within a six-monthperiod before the effective date of coverage. No benefits are available for pre-existingconditions for six (6) months after the effective date of coverage, unless priorcreditable coverage exists. This limitation does not apply for members under the ageof 19.Per individual,/calendar yearIn-Network: Family deductible is two timesindividual amount.Out-of-Network: Family deductible is twoand half (2.5) times the individual amount.Per individual/calendar year.Includes core medical coinsurance amountsonly; does not include deductible; copayments,penalty amounts; Vision and Rxcharges or Co-payments, charges in excessof Usual, Customary and Reasonablecharges, Premium payments or non-coveredbenefit charges. Out-of-Pocket maximum ison a calendar year basis.In-Network: Family limit is two timesindividual amount.Individual$1,000Family$2,000Individual$2,500Family$5,000Individual$2,000Family$5,000Individual$5,000Family$12,500Out-of-Network: Family limit is two and half(2.5) times the individual amountLifetime Maximum None NoneMedical OfficeVisitsPreventive Care ServicesAnnual PhysicalsWell Baby/Child careImmunizationsPeriodic screenings and testsVision and Hearing Screening (formembers age 17 and under)ColonoscopyNo Charge 3 40%LINC 289-1010 Lovelace Insurance Company Page 2 of 9MCM20011

Classic PPO$20/20%/40%/$1,000 PlanCoveredServicesMedical OfficeVisits (continued)Inpatient HospitalServicesOutpatientSurgical andMedical ServicesDescriptionMedically Necessary surgical proceduresperformed in the physician’s officeDiagnosis & treatment of illness and injuryServices provided during an admission to anAcute Care Inpatient Facility, InpatientRehabilitation Care or Long-term Acute CareInpatient FacilitySemiprivate Room and BoardPhysician, Surgeon and AnesthesiologistservicesOperating, and Recovery roomsDrugs and MedicationsServices provided in an outpatient facilitysetting including:Pre-surgical testingOperating, recovery & other treatmentroomsPhysician and surgeon servicesAnesthetics and anesthesia servicesDiagnostic laboratory tests, x-rays andpathology servicesAdministration of blood, blood plasmaand other biologicalsAdministration of Injections and InfusionsBlood transfusionsRadiation Therapy and ChemotherapyDialysis (member must apply forMedicare)Member Deductibles,Co-payment & CoinsuranceIn-NetworkParticipatingProviderNon-Specialist$20 co-payment/visitSpecialist$40 co-payment/visitOut-of-NetworkNon-ParticipatingProvider40%20% 40%20% 40%Emergency andUrgent CareServicesServices provided at a hospital emergencyroom , emergency outpatient facility ordesignated urgent care facilityEmergency CareUrgent Care$100 Co-payment per visit$50 Co-payment per visitAcupunctureAllergy TreatmentNon-emergent or non-urgent follow-up care20% 40%Diagnostic and treatment services20% Not CoveredMaximum benefit: $1,500/calendar yearAllergy Services including Testing,Treatment, Serum extracts and Injections 20% 40%LINC 289-1010 Lovelace Insurance Company Page 3 of 9MCM20011

Classic PPO$20/20%/40%/$1000 PlanCoveredServicesAmbulanceServicesAutism SpectrumDisorder 4BehavioralHealth/MentalHealth TreatmentChiropracticCT/MRI/PETScansDiabetesCoverageDescriptionGround TransportAir TransportNon-emergency TransportMember Deductibles,Co-payment & CoinsuranceIn-NetworkParticipatingProviderProviderOut-of-NetworkNon-Participating$50 Co-payment per trip$100 Co-payment per trip20% 40%Speech, occupational and physical therapyApplied behavioral analysis 20% 40%Inpatient servicesHospitalizationPartial hospitalization (waived if followinginpatient hospitalization)Electroconvulsive Therapy (ECT)Outpatient servicesIndividual, family or couples therapyIntensive outpatient program (IOP)Group therapyElectroconvulsive Therapy (ECT)Diagnostic and treatment services20%20%Included in inpatientadmission charge$40 co-payment/visit$40 co-payment/visit$20 co-payment/visit$40 co-payment/visit40%20% Not CoveredMaximum benefit: $1,500/calendar yearMedically Necessary outpatient imagingtests 20% 40%Office visits/treatmentNon-Specialist orSpecialist CopaymentappliesDiabetic supplies and medicationsDiabetic durable medical equipment (DME)Refer to PrescriptionDrug Rider20%40%DiagnosticServicesDurable MedicalEquipmentEndoscopicProceduresDiabetic educationNon-surgical diagnostic testing, including:Blood testsUrinalysisPathology testsX-rays and ultrasoundsMammogramsNo chargeNo charge; includedwith Co-payment forapplicable visit/facilitycharge40%Medically Necessary services, supplies anddevices 20% Not CoveredMedically Necessary exams, tests andprocedures $40 co-payment/visit 40%LINC 289-1010 Lovelace Insurance Company Page 4 of 9MCM20011

Classic PPO$20/20%/40%/$1,000 PlanCoveredServicesExternalProstheticAppliancesFamily PlanningDescriptionMember Deductibles,Co-payment & CoinsuranceIn-NetworkParticipatingProviderOut-of-NetworkNon-ParticipatingProviderMedically Necessary services, supplies anddevices 20% Not CoveredTests and counselingNon-Specialist orSpecialist Co-paySurgical sterilization proceduresInpatient Facility ChargeOutpatient Facility ChargePhysician’s OfficeContraceptive implant insertion/re-insertion fee20%20%Non-Specialist orSpecialist Co-pay20%40%Hearing Aids andRelated Servicesfor DependentChildren 5Home HealthServicesHospice ServicesInfertilityContraceptive implant removalFitting and dispensing servicesHearing aidsPrescribed home physician services, andnursing care and rehabilitative therapy.Non-Specialist orSpecialist Co-payNon-Specialist orSpecialist Copaymentapplies20%40%20% 40%100 visits/calendar year combinedSpecified Hospice Care Services (which arereasonable and necessary for the palliationor management of terminal illness)20% 40%Lifetime Maximum benefit: $10,000 7Diagnosis and medically indicatedtreatments for physical conditions causinginfertilityNon-Specialist orSpecialist CopaymentOffice VisitappliesTreatment/Surgery – Infertility benefit arelimited to services for testing, diagnosis andcorrective procedures onlyIn-vitro fertilization and costs connected withcollection, preparation, storage of sperm forartificial insemination, including donor fees50% after deductibleNot CoveredNot CoveredInfertility drugsRefer to PrescriptionDrug RiderLINC 289-1010 Lovelace Insurance Company Page 5 of 9MCM20011

Classic PPO$20/20%/40%/$1,000 PlanCoveredServicesInfertility(continued)Maternity CareDescriptionMember Deductibles,Co-payment & CoinsuranceIn-NetworkParticipatingProviderOut-of-NetworkNon-ParticipatingProviderReversal of prior voluntary sterilizationsurgery Not Covered Not CoveredPrenatal and postpartum careDelivery – all physician and hospital servicesfor mother during confinement, including fullterm delivery, miscarriage or termination ofpregnancyNon-Specialist orSpecialist Copay/visit20%40%OutpatientShort TermRehabilitation 4Newborn child is covered from birth only ifenrolled within 31 days of birth 8Physical, Occupational, and SpeechTherapyCardiac RehabilitationPulmonary Rehabilitation20% Not CoveredSkilled Nursing Maximum of 60 days/calendar year 6 20% 40%Sleep StudiesSmoking/TobaccoCessationSubstance AbuseServicesTransplantsIncluding Overnight and non-overnightstay/visitsPrescription drugsCounselingInpatient ServicesAlcohol and drug abuse detoxificationRehabilitation 9Partial hospitalization (waived if followinginpatient hospitalization)Outpatient ServicesOutpatient DetoxificationIndividual, Family or Marital TherapyIntensive Outpatient Program (IOP)Group TherapyRefer to EOC for details of benefit,limitations and exclusions. Services must beobtained or provided by a Lovelacedesignated provider and facility.LIFETIME MAXIMUM: $1,000,00020% Not CoveredRefer to PrescriptionDrug RiderNon-Specialist orSpecialist Copaymentapplies20%20%20%$40 co-payment/visit$40 co-payment/visit$40 co-payment/visit$20 co-payment/visitApplicable copaymentorcoinsurance appliesbased on place ofservice.40%40%Not CoveredLINC 289-1010 Lovelace Insurance Company Page 6 of 9MCM20011

Classic PPO$20/20%/40%/$1,000 PlanENDNOTES:(*) Member is responsible for paying 100% of charges that exceed Usual, Customary and Reasonable Rates. “Usual, Customaryand Reasonable rates” means health care services, medical supplies and payment rates for health care services provided by ahealth care practitioner at or near the median rate paid for similar health care services within a surrounding geographic areawhere the charges were incurred. Surrounding geographic area may be determined by the type of service and access to thatservice in the geographic area.(1) Deductible must be met before benefit payments are made, unless otherwise noted. Additionally, the In-network and Out-of-Network deductibles are separate. Payments to In-network services contribute to the In-Network deductible only. Paymentsmade to Out-of-Network services contribute to the Out-of-Network deductible only.(2) After a member reaches the applicable out-of-pocket limit, Plan pays 100% of most of the covered In-network and Out-of-Network charges. Please refer to your EOC for details. The In-network and Out-of-Network maximums are separate.Payments to In-Network services contribute to the In-Network maximum only. Payments made to Out-of-Network servicescontribute to the Out-of-Network maximum only.(3) The Patient Protection and Affordable Care Act requires health plans to cover specific Preventive Care Services at no cost toour members when the services are provided by an In-Network Participating Provider. Though these specific services arecovered at no charge, the provider may charge a co-payment for other services provided during the office visit. Servicesreceived from an Out-of-Network/Non-Participating Provider are not covered. If you have questions regarding the PreventiveCare Services that are covered under your plan or your cost for these services, please contact the Lovelace Customer CareCenter.(4) These services must be Medically Necessary as defined by your Evidence of Coverage.(5) These services must be Medically Necessary as defined by your Evidence of Coverage. Services must be provided by anaudiologist, hearing aid dispenser or physician. Coverage is limited up to age 21.(6) These services have maximum day or visit limitations. Total numbers of visits/days is combined and cross accumulates byservice type and by provider/facility type (In-Network and/or Out-of-Network provider/facility).(7) The Lifetime Maximum benefit of $10,000 is a combined maximum including services provided by In-Network and/or Out-of-Network providers/facilities.(8) Newborn child is covered from birth only if enrolled within 31 days. Please refer to your EOC Handbook for enrollmentinformation.(9) Excludes rehabilitation at Residential Treatment Center (RTC’s) or other facilities using social models to provide rehabilitation.LINC 289-1010 Lovelace Insurance Company Page 7 of 9MCM20011

Programs for Better HealthWe are committed to helping you take charge of yourhealth by providing you with health-wise informationand resources. We encourage you to explore ourHealthy Steps benefit features, our interactive onlinetools and make use of the services and educationprovided.Healthy Steps ProgramsHealth CoachingBaby LoveHealthy TrailsWhen it Comes To Your Health, We’ve Got You CoveredEmergency Health Services are covered wherever yougo, World-Wide, 24 hours a day, 7 days a week.EMERGENCY HEALTH SERVICES are those servicesrequired to treat an accidental injury or the suddenonset of what reasonably appears to be a medicalcondition that manifests itself by symptoms of sufficientseverity, including severe pain, that the absence ofimmediate medical attention could be expected by areasonable layperson to result in jeopardy to a person'shealth, serious impairment of bodily functions, seriousdysfunction of a bodily organ or part or disfigurement toa person.Emergencies can vary widely. Some examples ofmedical emergencies are:Possible heart attack (severe chest pain or pressure)Have a Question or Concern?We value your questions and comments about the Planor your health care. Our Customer Care Center staffwill work with you to resolve any problems that you mayexperience during your membership. It is our goal toresolve any concerns you have as quickly and assatisfactorily as possible.Customer Care Center Representatives are available toassist you with your needs, including:Requesting a copy of the EOCEnrollment informationQuestions about Covered Services and BenefitsID Card replacementProcedures for obtaining careGreat care. Great choices.When you need care, you can feel confident knowingthat our network of providers and practitioners is closeto where you live and work. From your neighborhoodhealth care centers to acute care hospitals, ourstatewide network of contracted physicians, hospitalsand related medical services means you’re covered allacross New Mexico. For more information, pleasereview our Provider Directory.Case ManagementS.T.O.P.NurseAdvice New MexicoChoose HealthyHealth LiteracyHealthy WeightPersonal Health AssessmentCall 505.727.5344 or Toll-free 877.480.9368 forinformation on the Healthy Steps Program.Uncontrollable bleedingConfusion or loss of consciousness, especially aftera head injurySevere shortness of breath or difficulty breathingSevere or multiple injuries, including obviousfracturesIf faced with a life-threatening emergency, always seekimmediate care. Emergency rooms are highlyspecialized health care facilities. Go to the emergencyroom only for true emergencies, not for routine ailmentsor for convenience.Inpatient hospitalization for any Emergency Servicerequires notification to Lovelace Insurance Companywithin 48 hours of admission.Complaints or concernsInformation about Services that need to be Pre -Authorized by the PlanAppeals and Grievance proceduresStatus of claim paymentSe habla Español and most other languages. We havebilingual Spanish-speaking representatives and ourLanguage Line translates more than 140 otherlanguages.Customer Care Center505.727.5683 or toll-free 800.808.7363TTY 800.659.8331.The Provider Directory includes a listing of physicians,hospitals, pharmacies, medical equipment providers,laboratory, x-ray and other network providers. You mayalso access the directory via our website atwww.lovelacehealthplan.comor call the Customer Care Center for additional copies.LINC 289-1010 Lovelace Insurance Company Page 8 of 9MCM20011

Classic PPO$20/20%/40%/$1,000 PlanExclusions and LimitationsEXCLUSIONSRefer to the EOC Handbook for a complete listing of PlanExclusions. Your Plan provides coverage for MedicallyNecessary services. Pre-Authorization by the Plan MedicalDirector may be required for certain services to be covered.Your Plan does not provide coverage for the following, except asrequired by law:Alternative treatments including but not limited to aroma,massage or hypno therapyAny treatment, procedure, service, facility, equipment, drugs,drug usage, device or supply determined not to be MedicallyNecessary, except for those that are Authorized by the PlanArtificial aids including but not limited to hearing aids, devices orcomputers to assist in communication or speech, except asrequired by lawAutopsies and/or transportation costs for deceased membersBenefits and services not specified as Covered in this documentor the EOC HandbookCare for military service-connected disabilities for which theMember is legally entitled to and for which facilities arereasonably available to the MemberCharges that are determined to be unreasonable by the PlanCosmetic surgery or treatment except as Authorized by the Planor as listed in the EOC HandbookCustodial, domiciliary or respite careDental care, except as required by law and as written in the EOCHandbook (an optional benefit may be selected by your employergroup)Diapers and incontinence suppliesDrugs/medicines purchased without a doctor’s prescription.Prescription drugs are covered only when your employer grouphas selected the optional drug benefit, except as defined in theEOC Handbook, or as required by lawExpenses for services for which you have no legal responsibilityto pay, or for which a charge would not ordinarily be made in theabsence of coverage under this PlanExperimental services, investigational or unproven procedures orprotocols, including drugs or equipment, except as required bylawFoot care including but not limited to cutting or removal ofcorns/calluses, nail trimming, cutting or debriding, unlessdetermined to be Medically Necessary for the treatment ofdiabetesImmunizations, inoculations, exams, and other related servicesrequired for licensing, employment, marriage, insurance or travelpurposesInfant or baby food/formula or breast milk or other regular groceryproducts that can be processed for oral or tube feedingsInfertility & reproductive services/procedures including but notlimited to In-vitro, GIFT, ZIFT, surrogate parenting, reversal ofvoluntary sterilization, donor egg or sperm retrieval and storageNursing home care, except those services Authorized by the Planand provided in a Plan approved skilled nursing facilityEXCLUSIONS continuedOrthopedic shoes and foot orthotics, unless determined to beMedically Necessary for the treatment of diabetesRepairs for Durable Medical Equipment (DME), prosthetic ororthotic devices that were not provided by the PlanServices and procedures for sexual transformationServices for which other coverage is required to provide throughother arrangements, including but not limited to workers’compensation, automobile insurance or similar coverageServices/benefits related to the treatment of mental illness andsubstance abuse conditions that are not described in the Benefitsand Services or Limitations sections of the EOC Handbook;Excluded services/benefits include but are not limited toresidential treatment center (RTC) and treatment foster care(TFC) servicesServices of a provider which are not within his/her scope ofpracticeTravel, lodging and other related expenses, except as defined inthe EOC HandbookTreatment for sexual dysfunction, including but not limited tomedications, counseling and clinicsTreatment or services provided in connection with or to complywith involuntary commitments, police detention, court-orders orother similar arrangementsVision/eye refractive services and optical appliances, except asrequired by law and as written in the EOC Handbook (an optionalbenefit may be selected by your employer group)Vitamins (except Medically Necessary prenatal vitamins),minerals, food supplements (except Special Medical Foods asoutlined in the EOC Handbook)Vocational rehabilitation servicesWeight loss, physical conditioning programs or exerciseprograms of any typeLIMITATIONSRefer to the EOC Handbook for a complete listing of PlanLimitations. Your plan has limited coverage for the followingservices:AcupunctureAmbulance serviceBiofeedbackChiropractic servicesCircumstances beyond the Plan’s controlConsumable medical suppliesFamily planning evaluation and treatment servicesGrowth Hormone therapyHome Health ServicesLong-term rehabilitative therapyOrgan transplants, immunosuppressive drugs and transplantrelated travel and lodgingPodiatric servicesSkilled nursing and Rehabilitation servicesTobacco cessationVision and hearing screening/careLovelace Health Plan4101 Indian School Rd. NE | Albuquerque, NM 87110 | 505.727.5683 | 800.808.7363 | lovelacehealthplan.comLINC 289-1010 Lovelace Insurance Company Page 9 of 9MCM20011