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

Medical BenefitsPREVENTIVE CARE“Preventive Care” means routine treatment or examination provided when there is no objective indicationor outward manifestation of impairment of normal health or normal bodily function, which is not providedas a result of any Injury or Illness.Coverage under this benefit includes the following routine services:1. Routine Outpatient Well-Child Care for Well-child examinations by a Physician or Licensed HealthCare Providers, which will include a medical history, physical examination, developmentalassessment, and anticipatory guidance as directed by a Physician or Licensed Health CareProvider, laboratory tests and routine immunizations according to the schedule of immunizationswhich is recommended by the Advisory Committee on Immunization Practices (ACIP) that havebeen adopted by the Director of the Centers for Disease Control and Prevention.2. Routine Wellness Care for Covered Persons eight (8) years of age or older, including, routinephysical examination and any associated routine testing provided or ordered at the time of thephysical examination and immunizations according to the schedule of immunizations which isrecommended by the Advisory Committee on Immunization Practices (ACIP) that have beenadopted by the Director of the Centers for Disease Control and Prevention.3. Prostate Specific Antigen (PSA) test for men.4. Recommended preventive services as set forth in the recommendations of the United StatesPreventive Services Task Force (Grade A and B rating), the Advisory Committee on ImmunizationPractices of the Centers for Disease Control and Prevention, and the guidelines supported by theHealth Resources and Services Administration. The complete list of recommendations andguidelines can be viewed athttp://www.healthcare.gov/center/regulations/prevention/recommendations.html.5. Office visit charges only if the primary purpose of the office visit is to obtain a recommendedPreventive Care service identified above.Expenses payable under this Preventive Care benefit will not be subject to the Medical Necessityprovisions of this Plan. “Charges for Preventive care that involve excessive, unnecessary orduplicate tests are specifically excluded.”Charges for treatment of an active Illness or Injury are subject to the Deductible and BenefitPercentage and other plan provisions, limitations and exclusions and are not eligible in anymanner under Preventive Care.LACTATION BENEFITBenefit Limits apply as stated in the Schedule of Medical Benefits.Coverage under this benefit includes expenses related to lactation consultation, follow up, andbreastfeeding supplies to enable the nursing mother to return to work.Western Montana Providence Health & Services - SPD 26Group #2000204 - January 1, 2011