SCHEDULE OF BENEFITSFLEX ’99

HARRIS METHODIST TEXAS HEALTH PLAN, INC.d/b/a HARRIS METHODIST HEALTH PLAN

A Federally Qualified Health Maintenance Organization

611 Ryan Plaza Drive, Ste. 900Arlington, TX 76011-4009

817-462-7800800-633-8598

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CUSTOMER SERVICE DEPARTMENT

The Health Plan’s Customer Service Department can help You any time You have a problem or question. Call a representative at(817) 462-7800 or 1-800-633-8598 if You:

Need to change Your Primary Care Physician Have a benefit question Cannot reach Your Primary Care Physician Need any replacement documents (Member Guide, Schedule

of Benefits, Certificate of Coverage, Provider Directory, etc.) Need to replace a lost or stolen ID Card Need to update Your name, address, or phone number Have a complaint, problem, or suggestion Have any other questions about Your health care coverage.

WELLCALL PLUS

(817) 462-7800 or (800) 633-8598

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TABLE OF CONTENTS

WELCOME................................................................................................................................ 1

SCHEDULE OF BENEFITS........................................................................................................3

AMBULANCE SERVICES....................................................................................................6

CARDIAC REHABILITATION PROGRAM..........................................................................17

CHEMICAL DEPENDENCY SERVICES.............................................................................14

DENTAL SERVICES - LIMITED.........................................................................................19

DIABETIC SERVICES........................................................................................................10

DURABLE MEDICAL EQUIPMENT (DME).........................................................................18

EMERGENCY CARE SERVICES.........................................................................................5

FAMILY PLANNING SERVICES..........................................................................................9

HOME HEALTH SERVICES...............................................................................................15

INFERTILITY SERVICES.....................................................................................................9

INPATIENT FACILITY SERVICES.......................................................................................7

KIDNEY DIALYSIS SERVICES..........................................................................................11

MATERNITY SERVICES......................................................................................................8

MENTAL HEALTH SERVICES - INPATIENT......................................................................12

MENTAL HEALTH SERVICES - OUTPATIENT..................................................................12

SERIOUS MENTAL ILLNESS SERVICES..........................................................................13

ORGAN TRANSPLANT SERVICES...................................................................................11

OSTOMY SUPPLIES.........................................................................................................17

OUTPATIENT FACILITY SERVICES...................................................................................7

PHYSICIAN SERVICES.......................................................................................................4

PROSTHETIC MEDICAL APPLIANCES.............................................................................18

REHABILITATION SERVICES...........................................................................................16

SKILLED NURSING FACILITY SERVICES........................................................................14

SPEECH AND HEARING SERVICES................................................................................16

VISION SERVICES - LIMITED...........................................................................................20

GENERAL LIMITATIONS.........................................................................................................21

GENERAL EXCLUSIONS.........................................................................................................22

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WELCOME

Welcome to Harris Methodist Health Plan, referred to as “Health Plan” in this Schedule of Benefits. We have prepared this Schedule of Benefits to help explain the coverage provided by the Health Plan. It explains how to obtain medical care, what health services are covered, and what portion of the health care cost You are required to pay. You should refer to this information whenever You need medical services. You may request additional assistance by calling the Health Plan’s Customer Service Department at (817) 462-7800 or (800) 633-8598.

The Health Plan does not provide health care services, equipment, or supplies, but does coordinate a health care system to finance and deliver quality, cost-effective services to You.

You may choose to seek health care services outside the terms of this Schedule of Benefits; however, the Health Plan will only provide coverage for services received according to the terms of this Schedule of Benefits.

SELECTING A PRIMARY CARE PHYSICIAN

Your Primary Care Physician (PCP) is responsible for coordinating Your total health care. This includes initial care, routine care, home and office visits, and referrals. Upon enrollment, You must select a PCP from the Member Guide provided to You by the Health Plan, which includes physician addresses and telephone numbers. If You do not choose a PCP, the Health Plan will select one for You and notify You of the selection.

You may change Your PCP by contacting the Health Plan’s Customer Service Department. The change becomes effective on the first day of the month following Your request. The Health Plan may limit Your requests to change Your PCP to four changes in any twelve month period.

You may request health services by calling Your Primary Care Physician any time, day or night.

OBTAINING THE SERVICES OF A SPECIALIST PHYSICIAN

Based on Your health care needs, Your PCP will coordinate referrals to specialists, although You may directly access Participating Providers for mental health services and obstetrical/gynecological services. Mental health services are coordinated through Alliance of Behavioral Providers (ABP) whom You may contact directly by calling 817-462-6677 or 1-800-374-2129. Access to OB/GYN services is described in the next section. Referrals to specialists are valid only for the number of visits and/or time specified.

If a required specialty is not represented in the Health Plan network, Your PCP may request authorization for referral to a Non-Participating Provider for Covered Services. All such non-emergency referrals must be authorized by the Health Plan before services are obtained.

OBSTETRICAL & GYNECOLOGICAL SERVICES

A referral from Your Primary Care Physician is not required for obstetrical or gynecological care provided by a Participating Provider. You may directly contact the Participating Provider of Your choice for these services.

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ANNUAL DIAGNOSTIC EXAMINATIONS

Mammograms and prostate exams are covered under Your benefit plan. The Health Plan recommends that female Members receive mammograms and male Members receive prostate exams especially if You are considered to be in a high risk category. You may contact Your PCP to determine if You are considered to be in a high risk category and for the recommended frequency of exams.

MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES

You may access mental health and Chemical Dependency services directly by calling the Health Plan’s mental health management services at (817) 462-6677 or (800) 374-2129, or by requesting assistance from Your PCP.

PREAUTHORIZATION & THE UTILIZATION REVIEW PROGRAM

Preauthorization is the review of a requested service for Medical Necessity. This process helps ensure that You are receiving the most appropriate care available under this Schedule of Benefits.

Your Physician should contact the Health Plan before scheduling any service or admission requiring preauthorization. Some services which require preauthorization are:

Educational services; Inpatient and outpatient Facility services; Infertility services; Cardiac Rehabilitation services; Durable Medical Equipment; Organ Transplant services; and Home Health Care

REGARDING REFERRALS

In some cases, the Health Plan has designated certain utilization management functions to Physician groups or related entities. If the PCP You choose is affiliated with one of these arrangements, prior approval for specialist referrals may be required. You may wish to consult with Your PCP to determine if he or she is affiliated with an arrangement which requires approval for specialist referrals. Please refer to Your complaint and appeals procedures listed in Your Subscriber Certificate of Coverage for information regarding how to appeal any preauthorization decision.

Your PCP may also be a part of a Limited Provider Network or association of health professionals who work together to provide a full range of health care services. (A Limited Provider Network is a subnetwork within an HMO delivery network in which contractual relationships exist between Physicians, certain Providers, independent Physician associations and/or Physician groups which may limit the enrollees’ access to only the Physicians, Providers, and Hospitals in the subnetwork.)

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SCHEDULE OF BENEFITS

You are entitled to receive benefits for Covered Services that are Medically Necessary and described in this Schedule of Benefits. All services and benefits are subject to the stated Copayment amounts, Limitations, Exclusions, and provisions of the Group Health Care Agreement/Subscriber Certificate of Coverage and this Schedule of Benefits. Benefits may be added to this Schedule of Benefits by the addition of benefit Riders.

LIMITATIONS AND EXCLUSIONS

All benefits are subject to the stated Limitations and Exclusions. Each benefit section includes Limitations and Exclusions that apply to those benefits. General Limitations and Exclusions that apply to all benefits are listed at the end of this Schedule of Benefits.

REGARDING COPAYMENTS

This Schedule of Benefits shows different Copayments for different Covered Services. When a Provider performs two or more Covered Services on the same day, You pay only the higher Copayment. You would pay more than one Copayment for services on the same day if more than one Provider is involved, such as paying a Facility Copayment to the Hospital and a Physician Copayment to the doctor.

Copayments shown as a percentage of total charges means You pay the percentage of the rate the Health Plan has negotiated with that Provider. If there is not a negotiated rate, You pay the percentage of the rate charged by the Provider.

COPAYMENT MAXIMUMS

When the total Copayments applied to all Covered Services received by an individual Member reach the Per Member Copayment maximum, no Copayment will be required for additional Covered Services provided to that Member in the same Calendar Year.

When the total Copayments applied to all Covered Services received by a family reach the Per Family Copayment maximum, no Copayment will be required for additional Covered Services provided to any Member of that family in the same Calendar Year. It is possible that a family could reach the Per Family maximum without any one of the Members first reaching the Per Member maximum.

OUT-OF-POCKET MAXIMUM YOUR COST

Per MemberPer Family

$1,000$2,000

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PHYSICIAN SERVICES

BENEFITS YOUR COST

Primary Care Physician office visits for the diagnosis, care, and treatment of an Illness or Injury, including, but not limited to: Well-child care; Health assessments and screenings; Routine physical examinations; and Office surgery

$10/Visit

Specialist Physician office visits $10/VisitAnnual well-woman examinations $10/Visit-Primary Care Physician

$10/Visit-Specialist PhysicianPhysician home visits $10/Visit-Primary Care Physician

$10/Visit-Specialist PhysicianPhysician visits outside of scheduled office hours $25/VisitImmunizations administered in the office without an office visit Ages 0-6 years

Ages 7 years and older

No Copayment

No CopaymentInjections administered in the office without an office visit (allergy serum is not covered).

No Copayment

Allergy testing and diagnosis $10/Visit

Diagnostic services, laboratory tests, and x-rays performed in a Physician’s office

No Copayment

Professional radiology and pathology services No CopaymentProfessional anesthesia services No CopaymentPhysician services performed in an outpatient Facility No CopaymentPhysician services while You are confined in a Hospital or other inpatient Facility

No Copayment

Physician services in an emergency Facility No Copayment

EXCLUSIONS

Reports, evaluations, or physical examinations not required for treatment of health conditions, or not directly related to medical treatment. Examples include, but are not limited to, services (including immunizations) for: compliance with a court order, employment, insurance, camp, adoption, school, travel, or government licenses.

Allergy serum

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EMERGENCY CARE SERVICES

When faced with an emergency Illness or Injury, it is suggested You contact Your local emergency service or proceed to the nearest Emergency Care Facility. Upon arrival at the Facility or as soon as reasonably possible, You or someone You designate must contact Your Primary Care Physician. The Health Plan will pay for Emergency Care whether it is provided inside or outside the Health Plan’s Service Area.

Emergency Care means health care services provided in a Hospital emergency Facility or comparable Facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or Injury is of such a nature that failure to obtain immediate medical care could result in:

placing the Member’s health in serious jeopardy; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; serious disfigurement; or in the case of a pregnant woman, serious jeopardy to the health of the fetus.

The Health Plan will pay for medical screening examinations or other evaluations provided to You in the emergency department necessary to determine whether an emergency medical condition exists. The Health Plan will also pay for necessary Emergency Care services originating in a Hospital emergency department provided to You following stabilization of an emergency medical condition. The Health Plan must approve or deny coverage of post-stabilization care within the time frame appropriate to the circumstances, but in no case to exceed one hour.

Other Situations

If the Illness or Injury is not an emergency, contact Your PCP before seeking treatment. Your PCP will direct You to the most appropriate place of service. Your PCP, or someone he designates, is available 24 hours per day, seven days a week.

You may also contact WellCall Plus, the Health Plan’s personal health help line. Highly qualified nurses are available 24 hours a day to assist You if You or a covered family Member is sick, hurt, or in need of medical advice. After asking questions about Your symptoms, the nurse will help You decide on the appropriate level of care. We suggest You contact Your PCP following a call to WellCall Plus to update him on Your medical condition. Contact WellCall Plus at 1-800-633-8598 or through the Health Plan’s Customer Service Department at 817-462-7800.

If You have determined that Your condition does not require Emergency Care, but does need immediate attention from medical personnel, You may also choose to seek care from an Urgent Care center (minor emergency clinic). Urgent Care means health services provided in a situation other than in an emergency where a prudent layperson believes that the absence of treatment within a reasonable time would result in a serious deterioration of a person’s health.

Inpatient Admission Following Emergency Care Services

If You are admitted directly to an inpatient Facility from the emergency department of the same Facility, the emergency room Facility Copayment will be waived and You will pay the appropriate inpatient Facility Copayment.

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EMERGENCY CARE SERVICES (cont.)

BENEFITS YOUR COST

Emergency room Facility services inside or outside the Health Plan’s Service Area

$50/Visit

Urgent Care center services $25/Visit

Physician services in an emergency Facility No Copayment

LIMITATIONS

Benefits for Members temporarily outside the Service Area are limited to Emergency Care services. The Member must return to the Service Area to receive all other services and follow-up care from Participating Providers.

Coverage for services, supplies, or treatments not provided, referred, or authorized by Your PCP or the Health Plan is limited to coverage under this Emergency Care services benefit.

Coverage for services by Physicians, Facilities, or other Providers, who are not Participating Providers, is limited to coverage under this Emergency Care services benefit or to services preauthorized by the Health Plan

AMBULANCE SERVICES

BENEFITS YOUR COST

Land and air ambulance services $50 Copayment

LIMITATIONS

Ambulance services benefits are limited to: services provided in relation to covered Emergency Care services; or non-emergency services preauthorized by the Health Plan

Transportation or travel by means of any private or commercial carrier is limited to covered ambulance services

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INPATIENT FACILITY SERVICES

BENEFITS YOUR COST

All covered inpatient Facility services, medications, and supplies

$200 per admission

Physician services while You are confined in a Hospital or other inpatient Facility

No Copayment

Professional anesthesia services No Copayment

LIMITATIONS

Inpatient diagnostic testing is limited to services directly related to the condition for which the hospitalization is authorized.

EXCLUSIONS

Recreational or educational therapy

Private room accommodations when semi-private room accommodations are available

Private duty nursing in an inpatient Facility

OUTPATIENT FACILITY SERVICES

BENEFITS YOUR COST

Facility services for surgery or other procedure $50/Visit

Physician services for surgery or other procedure performed in an outpatient Facility

No Copayment

Professional radiology and pathology services No CopaymentProfessional anesthesia services No CopaymentDiagnostic services, laboratory tests, and x-rays(except MRI and CAT scan)

No Copayment

MRI and CAT scan No CopaymentChemotherapy and radiation therapy $10/Visit

LIMITATIONS

You will pay only the higher Copayment for Physician services when multiple services are performed by one or more Participating Physicians .

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MATERNITY SERVICES

BENEFITS YOUR COST

Physician services for obstetrical care,including pre-natal care, post-partum care, and Medically Necessary diagnostic services

$10 First Visit$10 Each Subsequent Visit

Physician services for maternity care and delivery while You are confined in a Hospital or inpatient Facility.

No Copayment

Physician services for care of an eligible newborn while confined in a Hospital or other inpatient Facility.

No Copayment

All covered inpatient Facility services, medications, and supplies

$200 per admission

Maternity education programs $10 per program

LIMITATIONS

Coverage for maternity services received outside the Service Area before week thirty-seven (37) of the pregnancy are limited to covered Emergency Care services benefits or services preauthorized by the Health Plan.

You must have preauthorization from the Health Plan to travel outside the Service Area (except for travel due to emergencies) after week thirty-six (36) of the pregnancy or services received outside the Service Area will not be covered.

Coverage for maternity services by Non-participating Providers is limited to Members who become eligible with the Health Plan after week thirty-one (31) of the pregnancy. All services must be authorized by the Health Plan before charges are incurred. All future obstetrical/gynecological services must be performed by a Participating Provider.

Maternity education programs require a referral from Your Physician and include prepared childbirth, Lamaze, teen pregnancy, cesarean section, vaginal birth after cesarean (VBAC), parenting, breast-feeding, and stress management during pregnancy.

Ultrasounds are limited to one (1) ultrasound per pregnancy unless additional ultrasounds are determined to be Medically Necessary.

EXCLUSIONS

Any procedure performed solely for sex determination of the fetus. Examples include, but are not limited to: ultrasound and amniocentesis.

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INFERTILITY SERVICES

BENEFITS YOUR COST

Physician office visits $10/Visit-Primary Care Physician$10/Visit-Specialist Physician

Diagnostic services, laboratory tests, and x-rays No Copayment

Intra-uterine and intra-cervical insemination with related sperm washing

$10 per procedure

Endometrial biopsy, hysterosalpingography, and diagnostic laparoscopy

$50 per procedure

LIMITATIONS

Infertility services benefits are limited to intra-uterine and intra-cervical insemination and diagnostic services to determine the cause of infertility.

Costs associated with the collection, storage, purchase, or processing of sperm is limited to those incurred for sperm washing for an intra-uterine or intra-cervical insemination procedure.

EXCLUSIONS

Infertility treatment, except intra-uterine and intra-cervical insemination

Any surgery or other procedure to correct a medical condition causing infertility for the purpose of enabling pregnancy

Infertility medications

Surrogate parenting

Any assisted reproductive technology (ART) procedure that enhances a woman’s ability to become pregnant, unless provided by Rider. Examples of ART procedures include, but are not limited to: GIFT procedures, ZIFT procedures, and in-vitro fertilization.

FAMILY PLANNING SERVICES

BENEFITS YOUR COST

Physician office visitsIncluding testing, counseling, genetic counseling, Federal Drug Administration approved contraceptive injections, the fitting or dispensing of an IUD or diaphragm, the removal of Norplant or similar device.

$10/Visit-Primary Care Physician$10/Visit-Specialist Physician

Physician services for Tubal Ligation No Copayment

Physician services for Vasectomy $10 per procedure

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FAMILY PLANNING SERVICES (cont.)

EXCLUSIONS

Reversal of sterilization

Subsequent resterilization

Insertion or supply of Norplant or any similar device

DIABETIC SERVICES

BENEFITS YOUR COST

Physician office visits for diabetic care $10/VisitDiabetic equipment and supplies $10 Copayment

Diabetic education No Copayment

LIMITATIONS

Medically Necessary covered diabetic equipment and supplies include:

blood glucose monitors, including monitors designed to be used by blind individuals; insulin pumps and associated appurtenances; insulin infusion devices; podiatric appliances for the prevention of complications associated with diabetes; test strips for blood glucose monitors; visual reading and urine test strips; lancets and lancet devices; syringes; insulin and insulin analogs; injection aids; prescriptive and nonprescriptive oral agents for controlling blood sugar levels; and glucagon emergency kits

Covered diabetic education programs must be Medically Necessary and preauthorized, and include:

diabetes care and self management training; and dietary counseling for diabetes management

Purchases of diabetic equipment and supplies is limited to a maximum of a thirty (30) day supply per Copayment.

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KIDNEY DIALYSIS SERVICES

BENEFITS YOUR COST

Outpatient services $10/Visit

Home Dialysis(continuous ambulatory peritoneal dialysis) including equipment, training, solutions, coils, and drug and surgical supplies

$10/Visit

ORGAN TRANSPLANT SERVICES

The Health Plan will provide benefits toward the following transplants when preauthorized by the Health Plan Medical Director or his designee:

kidney transplants; cornea transplants; liver transplants; pancreas transplants; bone marrow transplants; heart transplants; lung transplants; and/or any combination of these covered transplants

BENEFITS YOUR COST

All covered inpatient Facility services, medications, and supplies

$200 per admission

Physician services while You are confined in a Hospital or other inpatient Facility

No Copayment

EXCLUSIONS

Artificial Organ Transplants

Cross-species whole Organ Transplants

Organ donor transportation or lodging costs

Services provided to any Member for the donation of any organ or element of the body to a non-Member recipient

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OUTPATIENT MENTAL HEALTH SERVICES

Services for the evaluation and treatment of mental health conditions which do not require a program of daily treatment and for which services are provided on a per-visit basis.

BENEFITS YOUR COST

Maximum: 30 Days per yearCovered Services except group therapy and home health visits

$10/Visit

Group therapy and home health visits $10/Visit

Medication management $10/Visit-Primary Care Physician$10/Visit-Specialist Physician

Psychological testing $100/Visit

LIMITATIONS

Mental health services benefits for outpatient care services are limited to a maximum benefit of 30 visits per Calendar Year, and may include individual, family or group therapy and home health visits

INPATIENT MENTAL HEALTH SERVICES

Inpatient Mental Health Benefits include:

Psychiatric Day Treatment Facility/Structured Sub-acute Care - Provides treatment for individuals suffering from acute, mental and nervous disorders in a structured psychiatric program utilizing individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program. Each full day of treatment in a Psychiatric Day Treatment Facility shall be considered equal to one-half of one day of treatment of mental or emotional Illness or disorder in a Hospital or inpatient program.

Residential Treatment Center for Children and Adolescents - Provides residential care and treatment for emotionally disturbed children and adolescents and is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Hospitals, or the American Association of Psychiatric services for Children. Each two days of treatment in a residential treatment center will be considered equal to one day of treatment of mental or emotional Illness or disorder in a Hospital or inpatient program.

Crisis Stabilization Unit/Inpatient Care - Means a 24-hour residential program that is usually short-term in nature and that provides intensive supervision and highly structured activities to persons who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe proportions. Each two days in a Crisis Stabilization Unit are considered equal to one day of treatment of mental or emotional Illness or disorder in a Hospital or inpatient program.

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INPATIENT MENTAL HEALTH SERVICES (cont.)

BENEFITS YOUR COST

Maximum: 30 Days per yearCrisis Stabilization Unit/Inpatient Care FacilityPsychiatric Day Treatment/Structured Sub-acute Care, and/or Residential Treatment Center for Children and Adolescents

$200 per admission

Physician services while You are confined in a Hospital or other inpatient Facility

No Copayment

LIMITATIONS

Inpatient mental health services benefits are limited to a combined maximum benefit of 30 days per Calendar Year and may include evaluation, crisis intervention, and stabilization for the diagnosis and treatment of covered mental Illnesses or disorders.

SERIOUS MENTAL ILLNESS SERVICES

BENEFITS YOUR COST

Physician services for Serious Mental Illness $10/VisitAll covered inpatient Facility services, medications, and supplies

$200 per admission

Physician services while You are confined in a Hospital or other inpatient Facility

No Copayment

Outpatient Facility services $50/Visit

LIMITATIONS

All services must be provided in relation to a covered diagnosis or procedure

Treatment of Serious Mental Illness will mean treatment of the following psychiatric conditions as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM):

Schizophrenia; Paranoia and other psychotic disorders; Bipolar disorders (mixed, manic, depressive, and hypomanic); Major depressive disorders (single episode or recurrent); Depression in childhood or adolescence; Schizo-affective disorders (bipolar or depressive); Pervasive developmental disorders; or Obsessive-compulsive disorders

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CHEMICAL DEPENDENCY SERVICES

You are entitled to coverage of necessary care and treatment for Chemical Dependency on the same basis as that provided for any physical illness. Diagnosis and treatment for Chemical Dependency will include detoxification and/or rehabilitation on an inpatient or outpatient basis.

A series of treatments is a planned, structured, and organized program to promote chemical free status which may include different facilities or modalities and is complete when the Member:

is discharged on medical advice; has completed a series of these treatments without a lapse in treatment; or fails to materially comply with the treatment program for a period of 30 days

BENEFITS YOUR COST

Lifetime Maximum Benefit: Three separate series of treatments

Outpatient Care $10/Visit-Primary Care Physician$10/Visit-Specialist Physician

Inpatient Care/Crisis Stabilization Unit or Psychiatric Day Treatment Facility/Structured Sub-acute Care

$200 per admission

Physician services while You are confined in a Hospital or other inpatient Facility

No Copayment

EXCLUSIONS

Services provided by or at a residential treatment center

SKILLED NURSING FACILITY SERVICES

BENEFITS YOUR COST

Maximum Benefit: 60 days per Calendar YearAll covered inpatient Facility services, medications, and supplies

$200 per admission

Physician services while You are confined in an inpatient Facility for the purpose of skilled nursing services

No Copayment

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SKILLED NURSING FACILITY SERVICES (cont.)

LIMITATIONS

Skilled Nursing Facility services benefits are limited to: medical conditions subject to significant clinical improvement; and services provided instead of hospitalization, either in place of an admission or upon

discharge from inpatient care, or services determined Medically Necessary by the Health Plan based on acuity of

services and patient condition

HOME HEALTH SERVICES

BENEFITS YOUR COST

Home health services $10/Visit

Hospice (Home health service only) $10/Day

Growth hormones $10 per Vial

LIMITATIONS

Home health care services benefits are limited to services provided for: chemotherapy; radiation therapy; treatment of terminal illness; physical, occupational, respiratory, and/or speech therapy; or treatments determined by the Health Plan to be Medically Necessary and appropriate

to be rendered in a home setting

Hospice care received outside the home is provided under the inpatient Facility services benefit

EXCLUSIONS

Homemaker chores or similar services

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REHABILITATION SERVICES

BENEFITS YOUR COST

Rehabilitative services including occupational therapy, respiratory therapy, and/or physical therapy

Outpatient: $10/Visit

Inpatient: $200 per admission

Physician services while You are confined in a Hospital or other inpatient Facility

No Copayment

LIMITATIONS

Rehabilitation services benefits are limited to services that: prevent dysfunction, restore functional ability, or facilitate maximal adaption to impairment; are directed and monitored by a Participating Physician; are for therapy provided by a Physician or by a licensed or certified physical, occupational,

or respiratory therapist; are furnished to You by a Participating Facility or through a Participating Provider; and are provided according to a specific, written treatment plan that details the treatment,

including frequency and duration, and provides for on-going reviews.

EXCLUSIONS

Work hardening programs

SPEECH AND HEARING SERVICES

BENEFITS YOUR COST

Speech and/or hearing therapy Outpatient: $10/Visit

Inpatient: $200 per admission

Physician services while You are confined in a Hospital or other inpatient Facility

No Copayment

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SPEECH AND HEARING SERVICES (cont.)

LIMITATIONS

Speech and hearing benefits are limited to services that: prevent dysfunction, restore functional ability, or facilitate maximal adaption to impairment; are directed and monitored by a Participating Physician; are for therapy provided by a Physician or by a licensed or certified speech or hearing

therapist; are furnished to You by a participating Facility or through a Participating Provider; and are provided according to a specific, written treatment plan that details the treatment,

including frequency and duration, and provides for on-going reviews.

EXCLUSIONS

Work hardening programs

CARDIAC REHABILITATION PROGRAM

BENEFITS YOUR COST

Maximum Benefit: 36 sessions within 12 consecutive weeks per episodeOutpatient services $10/Visit

LIMITATIONS

Cardiac rehabilitation program benefits are limited to services provided immediately following:

a documented episode of unstable angina or myocardial infarction; or a coronary revascularization procedure

Cardiac rehabilitation programs must be medically supervised and EKG monitored.

OSTOMY SUPPLIES

BENEFITS YOUR COST

Maximum Benefit: $1,000 per Calendar Year

Ostomy supplies 20% of Total Charges

LIMITATIONS

Coverage of ostomy supplies is limited to: bags, stoma caps, skin cleanser, skin prep, paste, powder, dressings, syringes, sheaths, and gloves

Purchases of ostomy supplies are limited to a maximum of a thirty (30) day supply per Copayment

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PROSTHETIC MEDICAL APPLIANCES

BENEFITS YOUR COST

Maximum Benefit: unlimited per Calendar Year

Internal and external prosthetic appliances and applicable hardware

$10 per appliance

LIMITATIONS

Prosthetic medical appliances benefits are limited to appliances that: serve a basic physical or functional purpose; and are obtained from a participating prosthetic medical appliance Provider

Repair or replacement of external prosthesis is covered only when required by marked physical changes, growth, or malfunction of the device as determined by the Health Plan

The purchase of an external breast prosthesis and any associated garments is limited to purchase of the initial prosthesis and bra following mastectomy without reconstruction

EXCLUSIONS

Maintenance of any external device, appliance, equipment, or supply

Repairs to prosthetic medical appliances determined to be cosmetic by the Health Plan

DURABLE MEDICAL EQUIPMENT (DME)

BENEFITS YOUR COST

Maximum Benefit: unlimited per Calendar Year

Rental or purchase of medical equipment $10 per device

LIMITATIONS

Durable Medical Equipment (DME) benefits are limited to equipment that is: ordered by a Participating Physician; obtained from a participating DME Provider; able to withstand repeated use; primarily and customarily serve a medical purpose; not generally useful in the absence of Illness or Injury; and appropriate for use in the home

Replacement of Durable Medical Equipment is covered only when required by marked physical changes or growth

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DURABLE MEDICAL EQUIPMENT (DME) (cont.)

Breast pumps must be determined to be Medically Necessary by the Health Plan to be eligible for coverage

At Our option, the Health Plan maintains the right to rent or purchase approved equipment and maintains the right of possession of the equipment.

EXCLUSIONS

Repair or maintenance of any Durable Medical Equipment

LIMITED DENTAL SERVICES

BENEFITS YOUR COST

Maximum Benefit: $500 per Calendar YearLimited professional dental services for repair of accidental Injury to Sound Natural Teeth

20% of Total Charges

LIMITATIONS

Limited professional dental repair services are covered only when performed by a Participating Provider

Limited professional dental repair services benefits are limited to treatment: for the repair of accidental, non-occupational Injury to Sound Natural Teeth; begun within thirty (30) days of the accident; and completed within one hundred eighty (180) days of the accident.

Anesthesia and Hospital services for any dental care are limited to those available for Members who are unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the Member's Physician or the Dentist providing the dental care.

EXCLUSIONS

Repair or replacement of any implant, pontic, bridge, or denture

Appliances or splints for conditions involving the teeth, jaws, or tongue

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LIMITED DENTAL SERVICES (cont.)

Dental care, including, but not limited to: orthodontia services; fillings or other dental repair procedures; replacement of teeth, including fixed or removable prosthesis; treatment for diseases of the teeth or gums; extraction of teeth, including wisdom teeth; treatment for malocclusion or malposition of the teeth or jaws (mandibular or maxillary

hyperplasia or hypoplasia); Inpatient or outpatient surgery required for any dental care; prescription drugs for dental treatment; and x-rays

Dental services covered by any dental benefit plan through which the Member has other coverage for dental benefits

LIMITED VISION SERVICES

BENEFITS YOUR COST

Maximum Benefit: $75 per Calendar YearLimited vision services following cataract surgery, Congenital Anomaly repair, or accidental Injury

No Copayment

LIMITATIONS

Limited vision services benefits are limited to the purchase and fitting of the initial set of basic eyeglasses or initial contact lens following:

cataract surgery; repair of Congenital Anomaly; or accidental Injury when the natural lens has not been replaced by an internal prosthetic

lens

EXCLUSIONS

Radial keratotomy (RK), photorefractive keratotomy (PRK), and other keratoplasties or keratotomies

FLEX.199 Flex 10/200/100020

GENERAL LIMITATIONS

General Limitations that apply to Your benefits are listed in this section. Limitations that normally occur in relation to a specific benefit have been listed in the appropriate benefit section; however, all benefits are subject to all stated Limitations in this Schedule of Benefits.

1. Coverage is limited to those Covered Services that are Medically Necessary and provided in relation to a covered diagnosis or procedure.

2. Reconstructive surgery is limited to the reconstruction necessary to repair a dysfunction or disfigurement resulting from Injury, Illness, or Congenital Anomaly.

3. Breast reconstruction is limited to reconstruction of a breast, incident to mastectomy, to restore or achieve breast symmetry. This includes surgical reconstruction of a breast on which mastectomy surgery has been performed and surgical reconstruction of a breast on which mastectomy surgery has not been performed.

4. Charges submitted by a Facility as part of an inpatient confinement are limited to services related to the condition for which the confinement was approved.

5. Coverage for treatment of the temporomandibular joint (TMJ), including the jaw and the craniomandibular joint, is limited to those services for which coverage is mandated by the State of Texas. This includes only Medically Necessary diagnostic services and/or surgical treatment of conditions affecting the TMJ as determined to be Medically Necessary by the Health Plan Medical Director or his designee. All services must be provided by a Participating Provider. Surgical treatment of conditions affecting the TMJ must be preauthorized by the Health Plan. Charges related to dental services are not covered.

6. Benefits for covered prescription and non-prescription drugs, medications, and pharmaceuticals are limited to those covered items purchased and administered in a clinical setting by a Participating Provider. Formulas necessary for the treatment of phenylketonuria (PKU) or other heritable diseases are covered to the same extent as for drugs available only on the orders of a Physician.

7. Coverage for orthotics is limited to those services or products used in the treatment of all medical conditions other than for treatment of the foot and must be preauthorized by the Health Plan.

8. Coverage for blood and blood products is limited to those units which have not been replaced by or on behalf of a Member.

FLEX.199 Flex 10/200/100021

GENERAL EXCLUSIONS

General Exclusions that apply to Your benefits are listed in this section. Exclusions that normally occur in relation to a specific benefit have been listed in the appropriate benefit section; however, all benefits are subject to all stated Exclusions in this Schedule of Benefits. Please check any Rider(s) purchased with this Schedule of Benefits for possible coverage of any of these excluded services.

1. Any service or treatment for which You would not legally be required to pay in the absence of coverage provided by this Schedule of Benefits, except for Medicaid

2. Care for conditions that state or local law requires be treated in a public Facility

3. Care for military service-connected disabilities for which the Member is legally entitled to services and for which Facilities are reasonably available to the Member

4. Services rendered by an immediate relative of the Member or by a person who resides in the Member’s home. An immediate relative is the spouse, child, parent, grandparent, or sibling of the Member and includes in-law and step-family relationships formed through a current or previous marriage

5. Any medical, surgical, or health care procedure, service, device, or drug held to be Experimental or Investigational at the time it is performed, utilized, or administered, unless approved by the Health Plan

6. Services or products not for the specific treatment of Illness or Injury, including, but not limited to:

personal, convenience, or comfort items; personal kits provided upon admission to a Hospital; television; telephone; photographs; living accommodations or expenses, guest meals, or cots; finance charges; and announcements

7. Alternative methods of treatment including, but not limited to: acupuncture; naturopathy; psychosurgery; megavitamin therapy; nutritionally based alcoholism therapy; holistic or homeopathic care, including drugs; ecological or environmental medicine; hypnotherapy or hypnotic anesthesia; hippotherapy; and sleep therapy

8. Services primarily for rest, Custodial Care, Domiciliary Care, convalescent or respite care

9. Transsexual surgery, including medical or psychological counseling or hormonal therapy, in preparation for or subsequent to any such surgery

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GENERAL EXCLUSIONS (cont.)

10. Hearing aids, batteries, and examinations for the fitting of hearing aids, unless provided by Rider

11. Structural changes to a building or vehicle

12. Care and treatment of the exterior surfaces of the feet, including, but not limited to: removal or reduction of corns or calluses; arch supports or foot orthotics; trimming of nails; treatment of flat feet; braces; and splints

13. Treatment of obesity or complications of obesity treatment, regardless of associated medical or psychological condition, including, but not limited to:

intestinal or stomach bypass surgery; gastric stapling; wiring of the jaw; and insertion of gastric balloons

14. Services primarily to improve the Member’s appearance, which will not result in significant functional improvement, including, but not limited to:

plastic surgery; surgical treatment of keloid formation; rhinoplasty; scar revision; revision or reformation of sagging skin on any part of the body described as relating

to the eyelids, face, neck, abdomen, arms, legs, or buttocks; liposuction procedures; procedures performed in connection with the enlargement, reduction, implantation, or

appearance of a part of the body described as relating to the breast, face, lips, jaw, chin, nose, ears, or genitals;

hair replacement or transplantation; chemical applications or peels; abrasion of the skin; tattoo removal or camouflage; and electrolysis depilation

15. Drugs or substances not approved by the FDA, labeled “Caution - Limited by Federal Law to Investigational use,” or considered Experimental

16. Drugs used to treat hemophilia disorders

17. Formulas, dietary supplements, or special diets, except enteral nutritional products when approved by the Health Plan and those for the treatment of phenylketonuria (PKU) or other heritable diseases

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GENERAL EXCLUSIONS (cont.)

18. Aids, appliances, or supplies that possess features not required by the Member’s condition, are not primarily medical in nature, are self-help devices, are primarily for the Member’s comfort or convenience, are for common household use, are research equipment, or are deemed Experimental by the Health Plan, including, but not limited to:

corrective orthopedic shoes or arch supports; dentures; contact lenses; wigs or hair pieces; motor-driven wheel chairs and beds; bed boards, bathtub lifts, over-bed tables, adjustable beds, telephone arms, sauna

or whirlpool baths, chairs, elevators, car seats, or standing frames; stethoscopes, sphygmomanometers, or other blood pressure units; exercise equipment or enrollment in health or athletic clubs; air purifiers, air conditioners, or water purifiers; hypo-allergenic pillows or mattresses, or water beds; elastic stockings, garter belts, or corsets; cervical collars, slings, or traction apparatus; home testing kits or supplies; over-the-counter medications; and diapers, incontinence supplies, or other disposable supplies not otherwise specified

in this Schedule of Benefits

19. Excluded mental health services: services for psychiatric conditions that are chronic or organic in nature, or that will not

substantially benefit from short-term treatment; biofeedback; marriage, career, or financial counseling; treatment of mental retardation or mental deficiency; behavioral training; remedial education; evaluation and treatment of learning and developmental disabilities, and minimal

brain dysfunction; psychological testing or psychotherapy for the treatment of attention deficit disorders

or related conditions; and recreational or educational therapy

FLEX.199.1 Flex 10/200/100024