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

SCHEDULE OF MEDICAL BENEFITS - PROVPREFERRED PPOFORELIGIBLE PARTICIPANTS AND DEPENDENTSALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLANEXCLUSIONS AND MAXIMUM ELIGIBLE EXPENSE (MEE)THE BENEFIT PERIOD IS A CALENDAR YEARDEDUCTIBLE AND OUT-OF-POCKET MAXIMUMDeductible per Benefit PeriodPer Covered PersonPer FamilyOut-of-Pocket Maximum per Benefit PeriodPer Covered PersonPer Family*Includes DeductiblePRIMARY PPOSECONDARY PPO$1,500*$4,500*$250$750NON-PPO$3,500*$10,500*Primary PPO and Secondary PPO charges apply only toward the PPO Out-of-Pocket Maximumand Non-PPO charges apply only toward the Non-PPO Out-of-Pocket maximum.BENEFIT PERCENTAGEApplies unless specifically stated otherwise. SEE PPO BENEFIT FOR FURTHER DETAILSPrimary PPO Benefit PercentageBefore satisfaction of Out-of-Pocket Maximum ......................................90%After satisfaction of Out-of-Pocket Maximum.......................................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 Waived, Benefit Percentage 100%Western Montana Providence Health & Services - SPD 3Group #2000204 - January 1, 2011