[Ambetter Secure Care 1 (2018) with 3 Free PCP Visits-Standard Gold On Exchange Plan]

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1 [Plan Information] [Health Plan:] [Primary Member:] [Ambetter Secure Care 1 (2018) with 3 Free PCP Visits-Standard Gold On Exchange Plan] [John Doe] [Member ID:] [ ] [Date of Birth:] [08/12/62] [Effective Date:] [1/1/2018] [Last Coverage Change Date:] [1/1/2018] [Dependent Information] [First Name:] [Jane Doe] [Relationship to You:] [Spouse] [Birth Date:] [08/12/62] [Effective Date:] [1/1/2018] The Schedule of Benefits is a summary of services that may be covered under the plan. Benefits listed are subject to all provisions and limitations as outlined in the Evidence of Coverage (EOC). Please reference the EOC for details regarding the benefits listed below. The member is responsible for deductible, copayment or coinsurance applied to eligible service expenses. An overview of Preventive Services covered with no cost share can be found within your EOC. Ambetter Secure Care 1 (2018) with 3 Free PCP Visits-Standard Gold On Exchange Plan Benefit Insured Responsibility(per person) In-Network Providers Out-of-Network Providers Annual Deductible per Calendar Year $1,000 Individual $2,000 Family Not applicable Individual Not applicable Family Prescription Drug Deductible per Calendar Year $500 Individual $1,000 Family Not applicable Individual Not applicable Family Coinsurance For All Other Eligible 20% Coinsurance Not applicable Expenses Out-Of-Pocket Maximum per Calendar $6,350 Individual Not applicable Year $12,700 Family Physician Office Services Primary Care Physician and Other Practitioner Office Visit 3 free visits per person, 4th visit and after are subject to Deductible and Coinsurance. Your 3 free visits apply only to the provider s fee for the evaluation and management service. All other eligible services are subject to the Deductible and Coinsurance. Specialist Physician Office Visit* Preventive Care (including screenings, No charge Not covered immunizations and well-baby visits) Diagnostic Test (x-ray and lab-work)* Imaging Test (CT/PET scans, MRI)* Prescription Drugs Generic $10 Copay Not covered

2 Preferred Brand* $25 Copay after prescription drug Not covered combined with Non-Preferred and Specialty deductible Non-Preferred Brand* $75 Copay after prescription drug Not covered combined with Preferred and Specialty deductible Specialty* 30% Coinsurance after prescription Not covered combined with Non-Preferred and Preferred. drug deductible Covered at 100% after $350 eligible coinsurance charges applied per occurrence. Mail Order (90 day supply) 3 Times Retail Cost Sharing Not covered Outpatient Services Outpatient Facility* Outpatient Surgery Physician/Surgical Laboratory Outpatient and Professional Services Emergency and Urgent Care Services Emergency Room $250 Copay after deductible $250 Copay after deductible Emergency Transportation/Ambulance (Air* 20% Coinsurance after deductible 20% Coinsurance after deductible or Ground) Urgent Care Inpatient Hospital Services Inpatient Hospital Facility* Inpatient Hospital Physician and Surgical Mental Health and Substance Abuse Disorder Services, including Behavioral Health Treatment Mental/Behavioral Health Outpatient (PCP and Other Practitioner visits do not require Prior Authorization) Mental/Behavioral Health Inpatient Substance Abuse Disorder Outpatient (PCP and Other Practitioner visits do not require Prior Authorization) Substance Abuse Disorder Inpatient Maternity and Newborn Care Prenatal and Postnatal Care* Delivery and Inpatient Other Covered Services Home Health Care 120 visits per year Rehabilitation Outpatient 40 visits combined per year for Speech, Physical and Occupational Therapy and Chiropractic Care Habilitation 40 visits combined per year for Speech, Physical and Occupational Therapy and Chiropractic Care Skilled Nursing Facility* 60 days per year in a facility Durable Medical Equipment*

3 Hospice Chiropractic Care* Coverage limits for Outpatient Rehabilitation include Chiropractic Care. 40 visits combined per year for Speech, Physical and Occupational Therapy and Chiropractic Care Transplant Benefit* $10,000 for transportation and lodging per covered organ transplant Diabetes Care Management* Vision Services Pediatric (Up to 19 years of age) Exams and Eyewear $0 Copay Not covered Routine Eye Exam 100% Covered Not covered 1 Visit per year Eyeglasses (frames) and contacts 100% Covered Not covered 1 Item per year Lenses (per pair) Single 100% Covered Not covered Bifocal 100% Covered Not covered Trifocal 100% Covered Not covered Lenticular 100% Covered Not covered Contact Lenses Contact lenses (in lieu of 100% Covered Not covered glasses) Contact Lens Fitting 100% Covered Not covered Specialty Lens Fitting 100% Covered Not covered Wellness Programs; Disease or Case Management Programs; Other Programs $25 to $250 The benefit available for participation in a wellness program, a disease or case management program or another program will usually be in the form of a credit added to a debit card we issue to the member and, depending on the particular program, is usually between $25 and $250. Such credits may be one-time rewards, available periodically or related to specific requirements under a particular program. Discounts also may be available for participating in a program. You may obtain information regarding the available programs, the requirements for participation in each program and the benefits available for participating in a particular program by visiting our website at Ambetter.pshpgeorgia.com or by contacting Member Services by telephone at (TTY/TDD: ).

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