PHC SCHEDULE OF BENEFITS

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1 PHC SCHEDULE OF BENEFITS

personalized care that does not discriminate based on race, creed, or gender. FLORIDA HEALTH SOLUTION CORP, (FHS) would like to offer our members a guide that provides plan benefits information.

2 Thank you for choosing Florida Health Solution Corp, (FHS) as your Health Plan. Our Mission Florida Health Solution is created by a family for families in our community with the mission to provide a less costly alternative for health care and to provide quality, professional and personalized care that does not discriminate based on race, creed, or gender. FLORIDA HEALTH SOLUTION CORP, (FHS) would like to offer our members a guide that provides plan benefits information. The PHC SCHEDULE OF BENEFITS HANDBOOK is designed to keep information updated in accordance with offerd benefits. We assure you a professional and friendly staff whose only objective is to guide you step by step in answering your questions. If you have any questions or need assistance in obtaining an appointment, please contact our Customer Service Department at (305) (Miami Dade) and or (Other Counties). Office hours are Monday Friday from 9:00am to 6:00pm and Saturdays from 9:00am to 1:00pm. FLORIDA HEALTH SOLUTION, CORP. P.O BOX MIAMI, FLORIDA Florida Health Solution Corp. is a Florida licensed Prepaid Health Clinic & Discount Medical Plan Organization. PHC (Prepaid Health Clinic): Florida Health Solution Corp. is a Florida licensed prepaid health clinic (PHC). Members will pay Nominal copayment when receiving PHC healthcare services.

3 INDEX Office Visits... 3 Control Panels... 4 Optometry... 7 Endoscopy... 8 Diagnostics... 9 Additional Benefits... 16

SCHEDULE OF BENEFITS PRIMARY CARE PHYSICIAN/SPECIALIST OFFICE VISITS COVERED SERVICES DESCRIPTION CO-PAY¹ MIAMI-DADE Office Visit CO-PAY¹ BROWARD Office Visit CO-PAY¹ PALM BEACH & OTHER COUNTIES*

4 SCHEDULE OF BENEFITS PRIMARY CARE PHYSICIAN/SPECIALIST OFFICE VISITS COVERED SERVICES DESCRIPTION CO-PAY¹ MIAMI-DADE Office Visit CO-PAY¹ BROWARD Office Visit CO-PAY¹ PALM BEACH & OTHER COUNTIES* Office Visit GENERAL MEDICINE (FAMILY $5.00 $5.00 $5.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00 PRACTICE-PRIMARY CARE PHYSICIANS) DERMATOLOGY $20.00 $20.00 $20.00 $40.00 $40.00 $40.00 $40.00 $40.00 $40.00 GASTROENTEROLOGY ++ $20.00 $20.00 $30.00 $40.00 $40.00 $50.00 $40.00 $40.00 $50.00 GYNECOLOGY $20.00 $20.00 $20.00 $30.00 $30.00 $30.00 $30.00 $30.00 $30.00 INTERNAL MEDICINE $20.00 $20.00 $20.00 $30.00 $30.00 $30.00 $30.00 $30.00 $30.00 OPHTHALMOLOGY+ $40.00 $40.00 $60.00 $40.00 $40.00 $60.00 $40.00 $40.00 $80.00 ORTHOPEDIC $20.00 $20.00 $20.00 $40.00 $30.00 $30.00 $40.00 $40.00 $40.00 PEDIATRIC $20.00 $20.00 $20.00 $30.00 $30.00 $30.00 $30.00 $30.00 $30.00 PODIATRY $20.00 $20.00 $20.00 $30.00 $30.00 $30.00 $30.00 $30.00 $30.00 PSYCHIATRY $20.00 $30.00 $40.00 $30.00 $30.00 $40.00 $30.00 $30.00 $50.00 UROLOGY $20.00 $20.00 $20.00 $30.00 $30.00 $30.00 $40.00 $40.00 $40.00 CARDIOLOGY + $30.00 $30.00 $70.00 $30.00 $30.00 $70.00 $50.00 $40.00 $90.00 ENDOCRINOLOGY++ $20.00 $20.00 $70.00 $50.00 $40.00 $90.00 $50.00 $40.00 $90.00 NEUROLOGY + $40.00 $40.00 $65.00 $40.00 $40.00 $65.00 $40.00 $40.00 $75.00 OTOLARYNGOLOGY+ $30.00 $20.00 $50.00 $50.00 $50.00 $80.00 $50.00 $50.00 $80.00 PULMONOLOGY + $30.00 $30.00 $70.00 $30.00 $30.00 $70.00 $50.00 $40.00 $90.00 SURGEON + $30.00 $30.00 $40.00 $30.00 $30.00 $40.00 $40.00 $40.00 $60.00 ¹THE OFFICE VISIT CO-PAYMENT MUST BE PAID AT THE TIME THE SERVICE IS RENDERED. EXCEPT FOR TESTS PERFORMED AS SPECIFIED IN THE CONTROL PANELS AND ADDITIONAL BENEFITS SCHEDULES, LABORATORY AND DIAGNOSTIC PROCEDURES PERFORMED ARE SUBJECT TO A SEPARATE COPAYMENT. +THE MEMBER S PCP, GP OR SPECIALST MUST PROVIDE THE MEMBER WITH A REFERAL TO PLAN CONTROLLED SPECIALIST PHYSICIANS. *OTHER COUNTIES INCLUDE [PALM BEACH, ORANGE, OSCEOLA, SEMINOLE, HILLSBOROUGH, PINELAS AND PASCO] COUNTIES IN FLORIDA ++ CONTROLLED SPECIALTY VISIT REQUIRES A SIXTY (60) DAY WAITING PERIOD COMMENCING FROM THE MEMBER S COVERAGE EFFECTIVE DATE. FHS.PHC.OV.SB 11/13 3

5 CONTROL PANELS PANEL A: After a one (1) month waiting period commencing from the member s coverage effective date, a member is eligible for one preventive care check-up per contract year. The physical examination must be performed by a participating provider physician, general practitioner or pediatrician. PREVENTIVE PANELS B, C, D, AND F: After a three (3) month waiting period commencing from the member s coverage effective date, a member is eligible to have one of Panels B - F every 3 months per contract year. Panels A-F cannot be repeated and/or accumulated during each contract year. The procedure must be performed in a participating provider physician/specialist s based upon age specifications. PANEL H: After a one (1) month waiting period commencing from the member s coverage effective date, a member is eligible to have during an office visit either singular or multi lab tests (Panel H) performed 3 times per contract year. The first and second office visits whereby Panel H tests are performed are covered after the one month waiting period. The third office visits whereby Panel H tests are performed are covered only if the lab tests are performed more than three months after the second office visit. The tests must be medically necessary and be performed in the participating provider primary care physician or general practitioner s office. Panel H Lab tests can be combined with procedures from Preventive Panel female B and F, excluding other Panels. PANEL I: After a one (1) month waiting period commencing from the member s coverage effective date, a member is eligible to have procedures described in Panel I performed. This panel has a $ credit every contract year. This credit accumulates every contract year. If the full $ credit is not used during a contract year, the balance of the credit rolls over and is added to the next contract year s $200 credit amount. The procedure(s) must be performed in a participating provider physician/specialist s office or plan diagnostic center upon referral from a participating provider physician and subject to a previous appointment request, with the exception of child immunizations and flu shots. Must be medically necessary. PANEL J: After a one (1) month waiting period commencing from the member s coverage effective date, a member is eligible to have procedures described in Panel J once per contract year. The procedure must be performed by a participating provider dental office. FHS.PHC.CP.SB 07/13 4

6 CONTROL PANELS These panels are available once per contract year and must be performed in a participating plan provider s office. Panel A: ALL AGES CO-PAY Panel B: OLDER THAN 35 Female CO-PAY Male CO-PAY Office Visit BloodTest ( CBC, Comprehensive Metabolic Panel, Lipid Panel) Urinalysis $20 Office Visit Mammogram PAP Smear None Office Visit Prostate Test Coronary Risk Test None Panel C: OLDER THAN 40 CO-PAY Panel D: OLDER THAN 60 CO-PAY Office Visit Electrocardiogram Cholesterol and Triglycerides Chest X Ray (Smokers only) None Office Visit Occult Blood None Panel F: BETWEEN 21 AND 34 Female CO-PAY One Annual Office Visit including Pap Smear None FHS.PHC.CP.SB 07/13 5

7 CONTROL PANELS Panel H: ALL AGES LABORATORY TESTS CO-PAY All medically necessary multi or singular lab test(s) performed in accordance with the instructions above for Panel H. None Panel I: ALL AGES $ CREDIT PER CONTRACT YEAR CO-PAY X-rays Ultrasounds Children through age 11: Immunizations recommended by DHHS Members age 61 or older: Flu shots one time per contract year None One Annual Office Visit for: Oral Evaluation Basic cleaning (prophylaxis) Panel J: All AGES DENTAL PANEL CO-PAY None FHS.PHC.CP.SB 07/13 6

8 OPTOMETRY OPTOMETRY BASIC OPTION INTERMEDIATE OPTION INTEGRAL OPTION MEMBER CO-PAY $15.00 MEMBER CO-PAY $70.00 MEMBER CO-PAY $ SINGLE VISION BIFOCAL (FT 28) SINGLE VISION OPTIONS INCLUDE: PROGRESSIVE BIFOCAL (FT 28) SINGLE VISION VISION EXAM FRAME TINT UV PROTECTION CASE ADJUSTMENT TO GLASSES A member may choose from the following three options one time per Contract Year. FHS.PHC.V.SB 07/13 7

9 ENDOSCOPIC PROCEDURES LARINGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC $ UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) $ COLONOSCOPY, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) $ NOTE: THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. CO-PAYMENTS ARE ONLY APPLICABLE FOR THE PROCEDURE AND THE PHYSICIAN/ SPECIALIST FEES. THE MEMBER IS WHOLLY RESPONSIBLE FOR ALL INPATIENT OR OUTPATIENT FACILITY CHARGES IF THE PROCEDURE IS PERFORMED OUTSIDE THE PHYSICIAN/SPECIALIST S OFFICE. THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. FHS.PHC.E.SB 07/13 8

10 DIAGNOSTIC RADIOLOGY HEAD DIAGNOSTIC PROCEDURES MANDIBLE; LESS THAN FOUR VIEWS $ MASTOIDS; MINIMUM OF THREE VIEWS PER SIDE $ FACIAL BONES; MINIMUM OF THREE VIEWS $ NASAL BONES; MINIMUM OF THREE VIEWS $ ORBITS $ PARANASAL SINUSES; MINIMUM OF THREE VIEWS $ SELLA TURCICA $ SKULL; LESS THAN FOUR VIEWS $ TEMPOROMANDIBULAR JOINT, OPEN & CLOSED MOUTH $16.00 CHEST CHEST, SINGLE VIEW, FRONTAL $ CHEST, TWO VIEWS, FRONTAL & LATERAL $ CHEST, COMPLETE, MINIMUM OF FOUR VIEWS $ RIBS, UNILATERAL; TWO VIEWS $ STERNUM, MINIMUM OF TWO VIEWS $ MAMMOGRAPHY, BILATERAL $50.00 G0202 DIGITAL MAMMOGRAPHY, BILATERAL $90.00 SPINE SPINE, SINGLE VIEW, SPECIFY LEVEL $ CERVICAL SPINE, ANTEROPOSTERIOR & LATERAL $ THORACIC SPINE, ANTEROPOSTERIOR & LATERAL $ LUMBOSACRAL SPINE, ANTEROPOSTERIOR & LATERAL $ SACRUM AND COCCYX, MINIMUM OF TWO VIEWS $21.00 PELVIS PELVIS, ANTEROPOSTERIOR ONLY $ HIP, COMPLETE,MINIMUM OF TOW VIEWS $21.00 NOTE: THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. THE PROCEDURE MUST BE PERFORMED IN A PLAN PHYSICIAN/SPECIALIST OFFICE OR PLAN DIAGNOSTIC CENTER.THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. *MIAMI-DADE AND BROWARD COUNTIES ** PALM BEACH AND ALL OTHER COUNTIES EXCEPT MIAMI-DADE AND BROWARD FHS.PHC.DP.SB 07/13 9

11 DIAGNOSTIC PROCEDURES UPPER EXTREMITIES CLAVICLE $ SCAPULA $ SHOULDER, MINIMUM OF TWO VIEWS $ HUMERUS, MINIMUM OF TWO VIEWS $ ELBOW, ANTEROPOSTERIOR & LATERAL VIEWS $ FOREARM, ANTEROPOSTERIOR & LATERAL VIEWS $ WRIST, ANTEROPOSTERIOR & LATERAL VIEWS $ HAND, MINIMUM OF THREE VIEWS $ FINGER(S), MINIMUM OF TWO VIEWS $20.00 LOWER EXTREMITIES FEMUR, ANTEROPOSTERIOR & LATERAL VIEWS $ KNEE, TWO OR THREE VIEWS $ TIBIA & FIBULA, ANTEROPOSTERIOR & LATERAL VIEWS $ ANKLE, COMPLETE, MINIMUM OF THREE VIEWS $ FOOT, COMPLETE, MINIMUM OF THREE VIEWS $ CALCANEUS, MINIMUM TOW VIEWS $ TOES, MINIMUM TOW VIEWS $20.00 ABDOMEN ABDOMEN, SINGLE ANTEROPOSTERIOR VIEW (KUB) $ ABDOMEN, TWO VIEWS (DECUBITUS & ERECT) $ ESOPHAGOGRAM $ UPPER GASTROINTESTINAL TRACT WITH KUB $ UPPER GASTROINTESTINAL TRACT WITH SMALL BOWEL $ COLON, BARIUM ENEMA $ CHOLECYSTOGRAPHY, ORAL CONTRAST $ PYELOGRAPHY INTRAVENOUS $93.00 NOTE: THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. THE PROCEDURE MUST BE PERFORMED IN A PLAN PHYSICIAN/SPECIALIST OFFICE OR PLAN DIAGNOSTIC CENTER.THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. *MIAMI-DADE AND BROWARD COUNTIES ** PALM BEACH AND ALL OTHER COUNTIES EXCEPT MIAMI-DADE AND BROWARD FHS.PHC.DP.SB 07/13 10

12 DIAGNOSTIC PROCEDURES DIAGNOSTIC ULTRASOUND HEAD & NECK SOFT TISSUES OF HEAD & NECK $41.00* $61.00** THYROID, PARATHYROID, PAROTID $41.00* $61.00** CHEST CHEST ECHOGRAPHY (INCLUDES MEDIASTINUM) $ BREST(S) ECHOGRAPHY (UNILATERAL OR BILATERAL) $45.00* $65.00** ABDOMEN & RETROPERITONEUM ABDOMINAL ECHOGRAPHY, COMPLETE $ LIVER ECHOGRAPHY $ GALLBLADDER ECHOGRAPHY $ PANCREAS ECHOGRAPHY $ SPLEEN ECHOGRAPHY $ RETROPERITONEAL ECHOGRAPHY, COMPLETE $ RENAL ECHOGRAPHY $ AORTA ECHOGRAPHY $45.00 PELVIS ECHOGRAPHY, PREGNANT UTERUS $ TRANSVAGINAL ECHOGRAPHY $ PELVIC ECHOGRAPHY (NONOBSTETRIC) $ PROSTATIC ECHOGRAPHY $ BLADDER ECHOGRAPHY $40.00 NOTE: THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. THE PROCEDURE MUST BE PERFORMED IN A PLAN PHYSICIAN/SPECIALIST OFFICE OR PLAN DIAGNOSTIC CENTER.THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. *MIAMI-DADE AND BROWARD COUNTIES ** PALM BEACH AND ALL OTHER COUNTIES EXCEPT MIAMI-DADE AND BROWARD FHS.PHC.DP.SB 07/13 11

13 DIAGNOSTIC PROCEDURES GENITALIA SCROTUM & CONTENTS ECHOGRAPHY $ PROSTATIC TRANSRECTAL ECHOGRAPHY $93.00 EXTREMITIES EXTREMITY ECHOGRAPHY, NON-VASCULAR (eg, AXILLAE) $45.00 CEREBROVASCULAR ARTERIAL STUDIES CAROTID DOPPLER, COMPLETE BILATERAL STUDY $60.00* ** EXTREMITY ARTERIAL STUDIES $60.00* DOPPLER OF UPPER OR LOWER EXTREMITY ARTERIES, ** COMPLETE BILATERAL STUDY EXTREMITY VENOUS STUDIES DOPPLER OF UPPER OR LOWER EXTREMITY VEINS, COMPLETE $60.00* BILATERAL $100.00** CARDIOLOGY PROCEDURES ELECTROCARDIOGRAM WITH AT LEAST 12 LEADS, WITH $20.00 INTERPRETATION AND REPORT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS $75.00 WITH PHYSICIAN INTERPRETATION AND REPORT (HOLTER MONITOR) STRESS TEST (PLAIN) $ NOTE: THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. THE PROCEDURE MUST BE PERFORMED IN A PLAN PHYSICIAN/SPECIALIST OFFICE OR PLAN DIAGNOSTIC CENTER.THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. *MIAMI-DADE AND BROWARD COUNTIES ** PALM BEACH AND ALL OTHER COUNTIES EXCEPT MIAMI-DADE AND BROWARD FHS.PHC.DP.SB 07/13 12

14 DIAGNOSTIC PROCEDURES ECHOCARDIOGRAPHY ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL TIME WITH IMAGE DOCUMENTATION (2M) WITH OR WITHOUT M-MODE $100.00* RECORDING, COMPLETE $130.00** DOPPLER ECHOCARDIOGRAPHY COLOR FLOW SLEEP TESTNG SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, ATTENDED OR UNATTENDED BY A $ TECHNOLOGIST MAGNETIC RESONANCE IMAGING & COMPUTARIZED AXIAL TOMOGRAPHY COVERED SERVICES DESCRIPTION CO-PAY MAGNETIC RESONANCE IMAGING WITH CONTRAST MATERIAL(S) $ MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST MATERIAL(S) $200.00* $225.00** MAGNETIC RESONANCE IMAGING WITH & WITHOUT CONTRAST $ MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY WITH CONTRAST MATERIAL(S) $ COMPUTERIZED AXIAL TOMOGRAPHY WITHOUT CONTRAST MATERIAL(S) $ COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMINAL; WITH CONTRAST $ MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMINAL; WITHOUT $ CONTRAST MATERIAL(S) NOTE: THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. THE PROCEDURE MUST BE PERFORMED IN A PLAN PHYSICIAN/SPECIALIST OFFICE OR PLAN DIAGNOSTIC CENTER.THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. *MIAMI-DADE AND BROWARD COUNTIES ** PALM BEACH AND ALL OTHER COUNTIES EXCEPT MIAMI-DADE AND BROWARD FHS.PHC.DP.SB 07/13 13

15 SCHEDULE OF BENEFITS DIAGNOSTIC PROCEDURES NUCLEAR MEDICINE COVERED SERVICES DESCRIPTION CO-PAY THALLIUM STRESS TEST $ BONE SCAN / FLOW $ TESTICULAR SCAN $ THYROID UPTAKE SCAN $ LIVER FLOW SCAN $ RENAL FLOW SCAN $ GALLBLADDER SCAN $ BRAIN FLOW SCAN $ LUNG SCAN $ GI BLEEDING SCAN $ GALLIUM SCAN $ RED CELL VENOGRAM $ MECKEL S DIVERTICULUM SCAN $ PYB $ PIPIDA SCAN $ NOTE: THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. THE PROCEDURE MUST BE PERFORMED IN A PLAN PHYSICIAN/SPECIALIST OFFICE OR PLAN DIAGNOSTIC CENTER.THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. *MIAMI-DADE AND BROWARD COUNTIES ** PALM BEACH AND ALL OTHER COUNTIES EXCEPT MIAMI-DADE AND BROWARD FHS.PHC.DP.SB 07/13 14

16 DIAGNOSTIC PROCEDURES ECHOCARDIOGRAPHY ELECTROENCEPHALOGRAM $ NERVE CONDUCTION VELOCITY (UPPER) $ NERVE CONDUCTION VELOCITY (LOWER) $ BONE DENSITOMETRY COVERED SERVICES DESCRIPTION CO-PAY BONE MINERAL DENSITY ONE OR MORE SITES $75.00 NOTE: THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. THE PROCEDURE MUST BE PERFORMED IN A PLAN PHYSICIAN/SPECIALIST OFFICE OR PLAN DIAGNOSTIC CENTER.THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. *MIAMI-DADE AND BROWARD COUNTIES ** PALM BEACH AND ALL OTHER COUNTIES EXCEPT MIAMI-DADE AND BROWARD FHS.PHC.DP.SB 07/13 15

17 ADDITIONAL BENEFITS CODE TYPE OF AFTER 12 MONTHS BENEFITS SERVICE - LABORATORY CBC W/O PLAT, URIANALYSIS, COMP METABOLIC SURGICAL PROCEDURE EVACUATION OF SUBUNGUAL HEMATOMA SPLINT SPLINT; FINGER X-RAY MANDIBLE; LESSS THAN FOUR VIEWS X-RAY NASAL BONES, MINIMUN OF THREE VIEWS X-RAY SELLA TURCICA X-RAY TEMPOROMANDIBULAR JOINT, OPEN & CLOSED MOUTH X-RAY CHEST, SINGLE VIEW FRONTAL X-RAY SPINE, SINGLE VIEW, SPECIFY LEVEL X-RAY PELVIS, ANTEROPORTERIOR ONLY X-RAY CLAVICLE X-RAY SCAPULA X-RAY ELBOW, ANTEROPOSTERIOR & LATERAL VIEWS X-RAY WRIST, ANTEROPOSTERIOR & LATERAL VIEWS X-RAY HAND, MINIMUN OF THREE VIEWS X-RAY FINGER(S), MINIMUN OF THREE VIEWS X-RAY CALCANEOUS, MINIMUN OF TWO VIEWS X-RAY TOES, MINIMUN OF TWO VIEWS X-RAY ABDOMEN, SINGLE ANTEROPOSTERIOR VIEW (KUB) CARDIOLOGY ELECTROCARDIOGRAM WITH AT LEAST 12 LEADS, WITH PROCEDURE INTERPRETATION AND REPORT A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 16

18 ADDITIONAL BENEFITS CODE TYPE OF AFTER 15 MONTHS BENEFITS SERVICE SPLINT SPLINT, FOREARM TO HAND STRAPPING STRAPPING,ELBOW OR WRIST STRAPPING STRAPPING,HAND OR FINGER STRAPPING STRAPPING, KNEWW STRAPPING STRAPPING,ANKLE STRAPPING STRAPPING,TOES STRAPPING STRAPPING,UNNA BOOT SURGICAL REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL, PROCEDURE WITHOUT GENERAL ANESTHESIA X-RAY MASTOID, MINIMUN OF THREE VIEWS PER SIDE X-RAY FACIAL BONES, MINIMUN OF THREE VIEWS X-RAY SKULL; LESS THAN FOUR VIEWS X-RAY PARANASAL SINUSES; MINIMUM OF THREE VIEWS X-RAY SKULL; LESS THAN FOUR VIEWS X-RAY CHEST, TWO VIWS, FRONTAL & LATERAL X-RAY RIBS, UNILATERAL; TWO VOEWS X-RAY STERNUM, MINIMUM OF TWO VIEWS X-RAY CERVICAL SPINE, ANTEROPOSTERIOR & LATERAL X-RAY THORACIC SPINE, ANTEROPOSTERIOR & LATERAL X-RAY LUMBOSACRAL SPINE, ANTEROPOSTERIOR & LATERAL X-RAY SACRUM & COCCYZ, MINIMUM OF TWO VIEWS X-RAY SHOULDER, MINIMUM OF TWO VIEWS X-RAY HUMERUS, MINIMUM OF TWO VIEWS X-RAY FOREARM, ANTEROPOSTERIOR & LATERALVIEWS X-RAY HIP, COMPLETE, MINIMUM OF TWO VIEWS X-RAY FEMUR, ANTEROPOSTERIOR & LATERAL VIEWS X-RAY KNEE, TWO OR THREE VIEWS X-RAY TIBIA & FIBULA, ANTEROPOSTERIOR & LATERAL VIEWS X-RAY ANKLE, COMPLETE, MINIMUM OF THREE VIEWS X-RAY FOOT,COMPLETE, MINIMUM OF THREE VIEWS X-RAY ABDOMEN, TWO VIEWS (DECUBITUS & ERECT) A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 17

19 ADDITIONAL BENEFITS CODE TYPE OF AFTER 18 MONTHS BENEFITS SERVICE SURGICAL PROCEDURE TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER SURGICAL PROCEDURE DEBRIDEMENT OF NAIL(S) BY ANY METHOD; ONE TO FIVE SURGICAL PROCEDURE DEBRIDEMENT OF NAIL(S) BY ANY METHOD; SIX OR MORE SURGICAL PROCEDURE AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE SURGICAL INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE PROCEDURE THAN LOCAL TREATMENT IS REQUIRED SURGICAL PROCEDURE BURN DRESSING AND/ OR DEBRIDEMENT STRAPPING STRAPPING, SHOULDER (EG. VELPEAU) SPLINT APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) SURGICAL PROCEDURE REMOVAL FOREIGN BODY, INTRANASAL SURGICAL PROCEDURE REMOVAL IMPACTED CERUMEN, ONE OR BOTH EARS X-RAY CHEST, COMPLETE, MINIMUM OF FOUR VIEWS X-RAY CHOLECYSTOGRAPHY, ORAL CONTRAST ULTRASOUND BLADDER ECHOGRAPHY A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 18

20 ADDITIONAL BENEFITS CODE TYPE OF SERVICE AFTER 21 MONTHS BENEFITS ACNE SURGERY (MARSUPIALIZATION, OPENING OR REOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES) PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA OR CYST BIOPSY, PUNCTURE ASPIRATION OF CYST OF BREAST BIOPSY; EACH ADDITIONAL CYST OF BREAST ARTHROCENTESIS, ASPIRATION AND/ OR INJECTION; SMALL JOINT BURSA (EG. FINGERS, TOES) ARTHROCENTESIS, ASPIRATION AND/ OR INJECTION; INTERMEDIATE JOINT BURSA (EG. TEMPOROMANDIBULAR, ACROMIOCLAVICULAR. WRIST, ELBOW OR ANKLE, OLECRANON BURSA) ARTHROCENTESIS, ASPIRATION AND/ OR INJECTION; MAJOR JOINT BURSA (EG. SHOULDER, HIP, KNEE JOINT, SUBACROMIAL BURSA) SPLINT SPLINT; SHOULDER TO HAND (LONG ARM) SPLINT SPLINT, APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) X-RAY ESOPHAGOGRAM ULTRASOUND SOFT TISSUES OF HEAD & NECK ULTRASOUND THYROID, PARATHYROID, PAROTID ULTRASOUND CHEST ECHOGRAPHY (INCLUDES MEDIASTINUM) ULTRASOUND BREAST(S) ECHOGRAPHY (UNILATERAL OR BILATERAL) ULTRASOUND LIVER ECHOGRAPHY ULTRASOUND GALLBLADDER ECHOGRAPHY ULTRASOUND PANCREAS ECHOGRAPHY ULTRASOUND SPLEEN ECHOGRAPHY ULTRASOUND RENAL ECHOGRAPHY ULTRASOUND AORTA ECHOGRAPHY ULTRASOUND SCROTUM & CONTENTS ECHOGRAPHY ULTRASOUND EXTREMITY ECHOGRAPHY, NON-VASCULAR (EG. AXILLAE) D7110 DENTAL SINGLE TOOTH EXTRACTION (FIRST TOOTH) A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 19

21 ADDITIONAL BENEFITS CODE TYPE OF SERVICE AFTER 24 MONTHS BENEFITS INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE BIOPSY SKIN, SUBCUTANEOUS TISSUE AND/ OR MUCOUS MEMBRANE, SINGLE LESION BIOPSY, EACH SEPARATE / ADDITIONAL LESION REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 5 LESIONS EACH ADDITIONAL TEN LESIONS EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE DESTRUCTION BY ANY METHOD ALL BENIGN OR PREMALIGNANT LESIONS; UP TO 3 LESIONS DESTRUCTION BY ANY METHOD ALL BENIGN OR PREMALIGNANT LESIONS; 4TH THROUGH 14 LESIONS (EACH) DESTRUCTION BY ANY METHOD OF FLAT WARTS, MOLLUSCUM CONTAGIOUSUM, OR MILIA; UP 14 LESIONS CHEMICALCAUTERIZATION OF GRANULATION TISSUE INJECTION, TRIGGER POINT CAST SHOULDER TO HAND (LONG ARM) CAST ELBOW TO FINGER (SHORT ARM) CAST HAND AND LOWER FORE ARM (GAUNTLET) CAST APPLICATION OF CYLINDER CAST (THIGH TO ANKLE) CAST APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) CAST APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES). WALKER OR AMBULATORY TYPE CAST ADDING WALKER TO PREVIOUSLY APPLIED CAST ULTRASOUND PELVIC ECHOGRAPHY (NONOBSTETRIC) ULTRASOUND PROSTATIC ECHOGRAPHY ULTRASOUND ULTRASOUND CAROTID DOPPLER, COMPLETE BILATERAL STUDY DOPPLER OF UPPER OR LOWER EXTREMITY ARTERIES, COMPLETE BILATERAL STUDY ULTRASOUND DOPPLER OF UPPER OR LOWER EXTREMITY VEINS, COMPLETE BILATERAL STUDY A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 20

22 ADDITIONAL BENEFITS CODE TYPE OF SERVICE AFTER 27 MONTHS BENEFITS INCISION AND DRAINAGE OF ABSCESS; SIMPLE OR SINGLE INCISION AND DRAINAGE OF ABSCESS; COMPLICATED OR MULTIPLE INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE; CAST VELPEAU INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, ARM OR LEGS; LESION DIAMETER 1.0CM OR LESS EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, ARM OR LEGS; LESION DIAMETER 1.1CM TO 3.0CM EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.0 OR LESS EXCISION, OTHER BENIGN LESION, FACE, EARS, EYELIDS, NOSE LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.0 OR LESS EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER 2.0 OR LESS SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS, EYELIDS, NOSE, LIPS, AND/OR MUCOUS MEMBRANES CAST APPLICATION OF LONG LEG CAST (THIGH TO TOES) CAST APPLICATION OF LONG LEG CAST (THIGH TO TOES). WALKER OR AMBULATORY TYPE CAST WALKER OR AMBULATORY TYPE ENT PROCEDURE LARINGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC DESTRUCTION OF LESION(S), PENIS, (EG, CONDYLOMA, PAPILOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE CHEMICAL DESTRUCTION OF LESION(S), PENIS, ELECTRODESICCATION DESTRUCTION OF LESION(S), PENIS, CRYOSURGERY DESTRUCTION OF LESION(S), PENIS, LASER SURGERY DESTRUCTION OF LESION(S), PENIS, SURGICAL EXCISION DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 21

23 ADDITIONAL BENEFITS DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS X-RAY UPPER GASTROINTESTINAL TRACK WITH KUB X-RAY UPPER GASTROINTESTINAL TRACK WITH SMALL BOWEL X-RAY COLON, BARIUM ENEMA X-RAY PYELOGRAPHY INTRAVENOUS ULTRASOUND ABDOMINAL ECHOGRAPHY, COMPLETE ULTRASOUND RETROPERITONEAL ECHOGRAPHY, COMPLETE ULTRASOUND TRANSVAGINAL ECHOGRAPHY ULTRASOUND PROSTATIC TRANSRECTAL ECHOGRAPHY CARDIOLOGY PROCE- DURE CARDIOLOGY PROCE- DURE ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS WITH PHYSICIAN INTERPRETATION AND REPORT (HOLTER MONITOR) ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL TIME WITH IMAGE DOCUMENTATION (2M) WITH OR WITHOUT M-MODE RECORDING, COMPLETE, DOPPLER ECHOCARDIOGRAPHY COLOR FLOW A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 22

24 ADDITIONAL BENEFITS CODE TYPE OF SERVICE AFTER 30 MONTHS BENEFITS GASTROENTEROLOGY PROCEDURE EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, ARM OR LEGS; LESION DIAMETER OVER 3.1CM EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 3.0 CM EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 3.1CM EXCISION, OTHER BENIGN LESION, FACE, EARS, EYELIDS, NOSE LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 3.0 CM EXCISION, OTHER BENIGN LESION, FACE, EARS, EYELIDS, NOSE LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 3.1CM EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER OVER 2.1CM EXCISION, MALIGNANT LESION, SCALP NECK, HANDS, FEET, GENITALIA; DIAMETER 2.0 OR LESS EXCISION, MALIGNANT LESION, SCALP NECK, HANDS, FEET, GENITALIA; DIAMETER OVER 2.1CM EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.0CM OR LESS SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLA, EXTERNAL GENITALIA, TRUNK AND OR EXTREMITIES (7.5 CM OR LESS) SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLA, EXTERNAL GENITALIA, TRUNK AND OR EXTREMITIES SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLA, EXTERNAL GENITALIA, TRUNK AND OR EXTREMITIES SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE LIPS, MUCOUS MEMBRANES UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 GASTROENTEROLOGY PROCEDURE COLONOSCOPY, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) 23

25 ADDITIONAL BENEFITS BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE - CT -SCAN - CT - SCAN - CT - SCAN - CT - SCAN - MRI - MRI - NUCLEAR MEDICINE BONE SCAN / FLOW - NUCLEAR MEDICINE LIVER FLOW SCAN - NUCLEAR MEDICINE RENAL FLOW SCAN - NUCLEAR MEDICINE GALLBLADDER SCAN COMPUTERIZED AXIAL TOMOGRAPHY WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY WITHOUT CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY ABDOMINAL WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY ABDOMINAL WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE IMAGING WITH CONTRAST MATERIAL (S) MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST MATERIAL (S) - NUCLEAR MEDICINE BRAIN FLOW SCAN - NUCLEAR MEDICINE LUNG SCAN - NUCLEAR MEDICINE GALLIUM SCAN - NUCLEAR MEDICINE RED CELL VENOGRAM - NUCLEAR MEDICINE TESTICULAR SCAN - NUCLEAR MEDICINE THYROID UPTAKE SCAN - NUCLEAR MEDICINE GI BLEEDING SCAN - NUCLEAR MEDICINE MECKEL S DIVERTICULUM SCAN - NUCLEAR MEDICINE PIPIDA SCAN - NUCLEAR MEDICINE PYB PRE-PLAN SURGERY BIOPSY OF BREAST; OPEN INCISIONAL A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 24

26 ADDITIONAL BENEFITS PRE-PLAN SURGERY PRE-PLAN SURGERY MASTECTOMY, PARTIAL PRE-PLAN SURGERY PRE-PLAN SURGERY EXCISION OF CYST, FIBRO ADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRAN* HEMORRHOIDECTOMY INTERNAL AND EXTERNAL, SIMPLE; WITH FISSURECTOMY SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/ FISTULOTOMY); COMPLEX OR M* PRE-PLAN SURGERY LAPARASCOPY, SURGICAL; CHOLECYSTECTOMY PRE-PLAN SURGERY REPAIR INITIAL INGUAL HERNIA, REDUCABLE PRE-PLAN SURGERY LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUIAL HERNIA* PRE-PLAN SURGERY BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTUIPLE, ANY APPROACH PRE-PLAN SURGERY LAPAROSCOPY, SURGICAL, MYOMECTOMY* * MEMBERS ARE WHOLLY RESPONSIBLE FOR FINANCIAL LIABILITY, ALL INPATIENT AND OUTPATIENT FACILITY CHARGES FOR PROCEDURES PERFORMED OUTSIDE THE PLAN PHYSICIAN/ SPECIALIST S OFFICE OR DIAGNOSTIC FACILITY. PLEASE ALSO CONSULT YOUR CONTRACT FOR SERVICES SPECIFICALLY EXCLUDED FROM COVERAGE. NOTE: IN ORDER TO RECEIVE THE PROCEDURE AT NO CHARGE, THE FOLLOWING REQUIREMENTS MUST BE MET: THE PROCEDURE MUST BE MEDICALLY NECESSARY AS DETERMINED BY THE MEMBER S PLAN PHYSICIAN. AFTER 12 MONTHS OF MEMBERSHIP (INCLUDING SCHEDULES FOR AFTER 15, 18 AND 21 MONTHS), MEMBERS HAVE THE RIGHT TO RECEIVE THREE (3) OF THE PREVIOUS PANELS AT NO CHARGE. AFTER 24 MONTHS OF MEMBERSHIP (INCLUDING SCHEDULES OF 27, AND 30 MOTHS), MEMBERS HAVE THE RIGHT TO RECEIVE FOUR (4) OF THE PREVIOUS PANELS AT NO CHARGE. AFTER 36 MONTHS OF MEMBERSHIP (INCLUDING ALL OF THE ABOVE SCHEDULES PROCEDURES), MEMBERS HAVE THE RIGHT TO RECEIVE FIVE (5) OF THE PREVIOUS PANELS AT NOT CHARGE. THE MEMBER S PLAN PHYSICIAN MUST PROVIDE THE MEMBER WITH A REFERRAL FOR THE PROCEDURE. A member is entitled to a prescribed number of Coverage Services described in the Additional Benefits Schedule at no charge to the Member based on the length of time the Member has been covered under this Contract. FHS.PHC.AB.SB 07/13 25

27 Visiting our website: provides information to our members and is proud to offer health educational material through our Member Bulletins and other articles including preventive care, illness management and trends. Our members can also inform us of their health care experience and help us to improve our services by completing our online surveys. The activation of the online account will give access to personal information and important documentation to members. Take a minute to visit us online!!!!

CPT CODES. Ph: (307) Fax: (307) CATSCAN IV Contrast: 87.00

CPT CODES. Ph: (307) Fax: (307) CATSCAN IV Contrast: 87.00 Ph: (307) 382-4282 Fax: (307) 382-4291 CPT CODES CATSCAN IV Contrast: 87.00 74150 Abdomen w/o contrast $ 809.00 74160 Abdomen w/ contrast $1175.00 w/ contrast: $1262.00 74170 Abdomen w_w/o contrast $1324.00