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

SCHEDULE OF MEDICAL BENEFITS - PROVSELECT HSAFORELIGIBLE PARTICIPANTS AND DEPENDENTSALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLANEXCLUSIONS AND THE MAXIMUM ELIGIBLE EXPENSE (MEE)THE BENEFIT PERIOD IS A CALENDAR YEARHSA OPTION DEDUCTIBLE AND OUT-OF-POCKETMAXIMUMPRIMARY PPOSECONDARY PPONON-PPODeductible per Benefit PeriodSingle CoverageFamily CoverageOut-of-Pocket Maximum per Benefit PeriodSingle CoverageFamily Coverage*Includes Deductible$1,500$3,000$2,500*$5,000*Single Coverage means only the Employee is covered under the Plan.Family Coverage means the Employee and one or more Dependent(s) are covered under the Plan.BENEFIT PERCENTAGEApplies unless specifically stated otherwise. SEE PPO BENEFIT FOR FURTHER DETAILSPrimary PPO Benefit PercentageAfter satisfaction of Deductible .................................................100%Secondary PPO Benefit PercentageBefore satisfaction of Out-of-Pocket Maximum ......................................80%After satisfaction Out-of-Pocket Maximum.........................................100%Non-PPO Benefit PercentageBefore satisfaction of Out-of-Pocket Maximum ......................................50%After satisfaction of Out-of-Pocket Maximum.......................................100%MEDICAL BENEFITS / LIMITATIONSPRIMARYPPOSECONDARYPPONON-PPOSECOND SURGICAL OPINIONThe Physician rendering the second opinion regarding the Medical Necessity of such surgery must bequalified to render such a service, either through experience, specialist training or education, or similarcriteria, and must not be affiliated in any way with the Physician who will be performing the actualsurgery.Deductible Applies, Benefit Percentage 100%Western Montana Providence Health & Services - SPD 7Group #2000204 - January 1, 2011