I:\Legal\LEGAL\ST PATRICK HOSPITAL-Medical\Plan Document ...

Schedule of Medical Benefits - ProvPreferred PPOMEDICAL BENEFITS / LIMITATIONSEMERGENCY ROOM (Professional and Facility charges)Deductible Applies, Benefit Percentage after thespecified Copayment (waived if admitted within 24hours)INPATIENT REHABILITATION CARE (Facility charges only)PRIMARYPPO90% after $150CopaymentSECONDARYPPO90% after $150CopaymentNON-PPO90% after $150CopaymentDeductible Applies, Benefit Percentage 90% 80% 50%SKILLED NURSING FACILITY (Facility charges only)Deductible Applies, Benefit Percentage 90% 80% 50%PHYSICIAN / PROVIDER SERVICESDeductible Applies, Benefit Percentage --- 80% 50%ALTERNATIVE CARE (Chiropractic, Naturopathic and Acupuncturist)Deductible Applies, Benefit Percentage --- 80% 50%Covered Services, subject to the following benefit limits:‚ Chiropractic Care: office visits, spinal adjustments, manipulations and radiology.‚ Naturopathic: Office visits, preventive care, including women’s health, prenatal and postnatalmaternity care, diagnostic x-ray and lab services, nutritional counseling up to 2 visits per BenefitPeriod.‚ Acupuncturist: Office visits, pain management, treatment of asthma, substance abuse, nausearelated to pregnancy or chemotherapyCombined Maximum Benefit per Benefit Period / $1,500AMBULANCE SERVICESDeductible Applies, Benefit Percentage --- 80%MATERNITY (Global professional fees for prenatal visits, delivery, post-partum visits)Pregnancy for a Dependent child is excludedDeductible Applies, Benefit Percentage --- 80% 50%GENETIC AND INFERTILITY TESTING AND COUNSELING (Limited to certain conditions)Deductible Applies, Benefit PercentageMaximum Benefit per Benefit Period / $500--- 80% 50%OUTPATIENT REHABILITATION (Speech therapy, Occupational therapy, physical therapy andneurodevelopmental therapy)Deductible Applies, Benefit Percentage 90% 80% 50%ORTHOGNATHIC SERVICES, INCLUDING TMJ (Medical and Surgical)Deductible Applies, Benefit PercentageMaximum Lifetime Benefit / $3,000--- 80% 50%HOME HEALTH CAREDeductible Applies, Benefit Percentage --- 80% 50%Western Montana Providence Health & Services - SPD 5Group #2000204 - January 1, 2011