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1 Page 1 of 7 Print (Use Landscape) CHECK ELIGIBILITY - DETAIL Inquiry Date: 0 14:20:59 PST Date of Service Member Name Eligibility Status for the Requested DOS - Last Day of Coverage Spoken Language Date of Birth Provider Group # - Name Written Language Office Copay ** Benefit Detail Member ID Confirmation Primary Care Physician Eligible for Written Language Service? Product 0 PHAM, DAVID Active - t Available $ /06/ HEALTHCARE PARTNERS IPA-TALBERT t Available AE MICHAEL M DAO MD t Available HMO Please reference 'Employer Group Information' section to review detailed Plan Coverage Dates and eligibility information on this member. Member Information Insured Indicator Subscriber Gender Male Deductible Members will be required to pay for certain Covered Services until they have met their Annual Deductible. Only amounts incurred for Covered Services that are subject to the Deductible will count toward the Deductible. Plans may have an Individual Deductible only or both Individual and Family Deductible amounts. further Deductible will be required for the individual member when the Individual Deductible amount has been satisfied for the year. For s with both Individual and Family Deductibles, no further Deductible will be required for all members of the family unit when members of the family unit satisfy the Family Deductible for the year. As specified above, only certain Covered Services apply to the Annual Deductible. Covered Services not included in the Annual Deductible may incur a Member cost share that is considered separate from and not applied to the Annual Deductible. The Annual Deductible applies to the Annual Out-of-Pocket Maximum. The amounts applied to the Annual Deductible are based upon UnitedHealthcare's contracted rates. Plan Code Plan Effect Plan Amount Year-to-Date Remaining N/A Individual KGC 03/01/2012 Present $0.00 $0.00 $0.00 Family KGC 03/01/2012 Present $0.00 $0.00 $0.00 Annual Out-of-Pocket Maximum Annual Out-of-Pocket Maximum is the combined total of Annual Deductible (if any) and Annual Copayment Maximum (if any), as shown on the member's Schedule of Benefits. Cost sharing for certain types of Covered Services may not apply toward the Annual Outof-Pocket Maximum. Please refer to the member's Schedule of Benefits to determine applicability to the. When an individual member's Out-of-Pocket expenses have reached the Individual Out-of-Pocket Maximum, no further cost share amounts will be due by the member for those services that apply to the Out-of-Pocket Maximum. For s with both Individual and Family maximums, no further cost share amounts will be due by any member of the family for those services that apply to the Out-of-Pocket Maximum when a family's Out-of-Pocket expenses have reached their Family Out-of-Pocket Maximum. Plans with benefits that do not apply to the Outof-Pocket Maximum will still require cost sharing for those excluded benefits after the Out-of-Pocket Maximum has been reached. Cost share is defined as amounts to be paid by the member such as Copayments, Coinsurance and Deductibles according to their Plan Benefits. Plan Code Plan Effect Plan Amount Year-to-Date Remaining Individual KGC 03/01/2012 Present $1, $0.00 $1, Family KGC 03/01/2012 Present $3, $0.00 $3, Hospital Information Hospital Name DIRECTED BY PRIMARY MD Hospital Type UTILIZING Provider History

2 Page 2 of 7 Coverage Dates Provider Group # - Name PCP # - Name 03/01/2012-Present Employer Group Information HEALTHCARE PARTNERS IPA- TALBERT DAO, MICHAEL M Coverage Dates Employer Group # - Name Plan 03/01/2012-Present MERICAL, INC HMO ACT-ORANGE KGC Benefit Information Supplemental Benefits Benefit Category Copay $ Copay % Limit Limit Type Add Limit Ind Actual Available 15/30/45 30% UP TO $150SI O/P PRSCRP DRUGS-COPAY Days SV&SVA SMI+BH BUY-UP RIDER SMI/CHEM/MEN HLTH IP & OP ne Core Benefits Benefit Category Copay $ Copay % Limit Limit Type Add Limit Ind Actual Available Deductible Applies ALLERGY SERUM ne t a AUTOLOGOUS BLOOD ne t a BONE MARROW TRANSPLANT ne t a CHEMOTHERAPY SERVICES ne t a COCHLEAR IMPLANT DEVICE ne Units/Items t a DENTAL ANESTHESIA ne t a DEPO-PROVERA MEDICATION ne t a DIABETIC EQUIP/SUPPLIES ne t a DIAGNOSTIC SERVICES ne t a DME - PEDIATRIC ASTHMA ne t a DME-HCR ESSENTIAL ITEM ne Units/Items w calendar t a

3 Page 3 of 7 year usage DURABLE MEDICAL EQUIPMENT Dollars Units/Items w calendar year usage , t a EMERGENCY SERVICES ne Co-pay waived t a ER PHYSICIAN ne t a FOOT CARE ne t a HCR PREV CARE NO COPAY ne t a HEARING AID Dollars , t a HEARING AID BONE ANCHORED Count/Visits t a HOSPICE-HOME HEALTH Days Lifetime Max t a I/P BLOOD AND PLASMA ne t a I/P DETOXIFICATION ne t a I/P HOSPICE Days t a I/P HOSPITAL SERVICES ne t a I/P MATERNITY ne t a I/P NEWBORN CARE ne t a I/P PHYSICIAN ne t a

4 Page 4 of 7 I/P REHAB CARE ne t a I/P SKILLED NURSING Days t a I/P SURGEON/ANESTHESIOLOGT ne t a INFUSION THERAPY ne t a INTRA-UTERINE DEVICE/IUD ne t a O/P ALLERGY TESTING ne t a O/P ALLERGY TREATMENT ne t a O/P AMBULANCE ne Per trip t a O/P CHEMOTHERAPY DRUGS ne t a O/P DETOXIFICATION ne t a O/P FACILTY PHYSICIAN CARE ne t a O/P HEALTH EDUCATION ne t a O/P HEARING EXAM ne t a O/P HEARING SCRN AUDIOLOGY ne t a O/P HEMODIALYSYS ne t a O/P HOME CARE Count/Visits Per Visit t a O/P IMMUNIZATIONS ne t a O/P INJECTABLE DRUGS ne t a

5 Page 5 of 7 O/P INJECTABLES-SELF ADMIN ne t a O/P INSERT/REMOVE IUD ne t a O/P LAB AND RADIOLOGY ne t a O/P MATERIALS AND SUPPLIES ne t a O/P MATERNITY ne t a O/P MEDICAL SOCIAL SERVICE ne t a O/P PERIODIC HEALTH EVAL ne t a O/P PHYS,SPCH,OCC THERAPY ne t a O/P PHYSICIAN CARE ne t a O/P POST CATARACT MATERIAL ne t a O/P RADIATION THERAPY ne t a O/P REFRACTIONS Count/Visits Calendar / Benefit Year t a O/P REMOVE NORPLANT ne t a O/P SURGERY ne t a O/P TUBAL LIGATION ne t a O/P VASECTOMY ne t a O/P VISION SCREENING Count/Visits Calendar / Benefit Year t a O/P VOL ABORT-AFTER 1ST TR ne t a t a

6 Page 6 of 7 O/P VOL ABORTION-1ST TRI ne O/P WELL BABY CARE ne t a OFFICE VISIT COPAY ne t a ORAL SURGERY SERVICES ne t a ORTHOTICS ne Units/Items PROSTHETICS ne Units/Items t a t a RADIATION THERAPY-COMPLEX ne 30 Days or Treatment Plan t a SPECIALIZED SCAN & IMAGING ne Units/Items t a URGENT CARE - OUT OF AREA ne Co-pay waived t a URGENT CARE-IN AREA ne t a For any Benefit Details, please Contact Us. N/A means "t Applicable ". * Active - PCP Effective Date. * Termed - Plan Termination Date. ** The Office Visit Copay information shows two figures, the first is for PCP and the second is for Specialist. ** Hospital Copay may be either or Per Day. Please review Member's ID card or call customer service. *** Validate with Schedule of Benefits. Applies to UnitedHealthcare HMO members only: The newborn copayment applies only if the newborn is not discharged at the same time as the mother. Some services require prior authorization to avoid denial/penalties. Please refer to the current Pre-authorization List for details. UnitedHealthcare and Secure Horizons eligibility information systems provide you with the most current eligibility information available to UnitedHealthcare and Secure Horizons. Information is current as of close of previous business day. This information does not constitute approval or authorization of any service. All UnitedHealthcare and Secure Horizon inpatient admissions must be reported to the Medical Management Department All emergency services need to be reported to the contracting medical group or UnitedHealthcare within 24 hours for UnitedHealthcare members and 48 hours for Secure Horizons members.

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