Common use of Labor Management Healthcare Committee Clause in Contracts

Labor Management Healthcare Committee. The Union shall be entitled to continue to participate in statewide Labor Management Healthcare Committee meetings. Article 24, Appendix K-2 HEALTH INSURANCE BENEFIT CHART P r e v e n t i v e S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Health maintenance exam Covered 100% 1 per year Not Covered Covered 100% Annual gynecological exam Covered 100% 1 per calendar year Not Covered Covered 100% Pap smear screening – laboratory services only 1 Covered 100% 1 per year Not Covered Covered 100% Well-baby and child care Covered 100% Not Covered Covered 100% Immunizations, annual flu shot & Hepatitis C screening for those at risk Covered 100% Not Covered Covered 100% Childhood Immunizations Covered 100% through age 16 Covered 80% Covered 100% Fecal occult blood screening 1 Covered 100% Not Covered Covered 100% Flexible sigmoidoscopy 1 Covered 100% Not Covered Covered 100% Prostate specific antigen screening 1 Covered 100% one per year Not Covered Covered 100% Mammography, annual standard film or digital mammography screening 1 Covered 100% Covered 80% after deductible Covered 100% Colonoscopy 1 Covered 100% Covered 80% after deductible Covered 100% 1 Patient Protection and Affordable Care Act (PPACA) guidelines apply P h y s i c i a n O f f i c e S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Office visits, consultations and urgent care visits Covered, $20 co-pay Covered 80% after deductible Covered, $20 co-pay Outpatient and home visits Covered 90% after deductible Covered 80% after deductible Covered, $20 co-pay E m e r g e n c y M e d i c a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Hospital emergency room for medical emergency or accidental injury Covered, $200 co-pay if not admitted Covered, $200 co- pay if not admitted Ambulance services – medically necessary Covered, 90% after deductible Covered, 100% after deductible D i a g n o s t i c S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Laboratory and pathology tests Covered 90% after deductible Covered 80% after deductible Covered 100% Diagnostic tests and x-rays Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Radiation therapy Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible M a t e r n i t y S e r v i c e s Includes care by a certified nurse midwife (State Health Plan PPO only) State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Prenatal care Covered 100% Covered 80% after deductible Covered 100% Postnatal care Covered 90% after deductible Covered 80% after deductible Covered, $20 co-pay Delivery and nursery care Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible H o s p i t a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Semi-private room, inpatient physician care, general nursing care, hospital services and supplies Covered 90% after deductible, unlimited days Covered 80% after deductible, unlimited days Covered 100% after deductible Unlimited days Inpatient consultations Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Self-donated blood storage prior to surgery Covered 90% after deductible Covered 80% after deductible Check with your HMO Chemotherapy Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible A l t e r n a t i v e s t o H o s p i t a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Skilled nursing care up to 120 days per confinement Covered 90% after deductible Covered 100% after deductible Hospice care Covered 100% Limited to the lifetime dollar maximum that is adjusted annually by the State Covered 100% after deductible Home health care Covered 90% after deductible, unlimited visits Check with your HMO S u r g i c a l S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Surgery—includes related surgical services. Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Male Voluntary sterilization Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Female Voluntary sterilization Covered 100% Covered 80% after deductible Covered 100% H u m a n O r g a n a n d T i s s u e T r a n s p l a n t s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Liver, heart, lung, pancreas, and other specified organ transplants Covered 100% In designated facilities only. Up to $1 million lifetime maximum for each organ transplant Covered 100% after deductible in designated facilities Bone marrow—specific criteria apply Covered 100% after deductible in designated facilities Covered 100% after deductible in designated facilities Kidney, cornea, and skin Covered 90% after deductible in designated facilities Covered 80% after deductible Covered 100% after deductible subject to medical criteria O t h e r S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Allergy testing and therapy (non- injection) Covered 90% after deductible Covered 80% after deductible Covered,100% after deductible. Allergy injections Covered 90% after deductible Covered 80% after deductible Covered 100% Acupuncture Covered 80% after deductible if performed by or under the supervision of a M.D. or D.O. Check with your HMO Rabies treatment after initial emergency room visit Covered 90% after deductible Covered 80% after deductible Office visits: $20 co- pay. Injections: Covered 100% Autism Spectrum Disorder Applied Behavioral Analysis (ABA) treatment Covered 90% after deductible Covered 80% after deductible Covered,100% after deductible Chiropractic/spinal manipulation Covered, $20 co-pay Up to 24 visits per calendar year Covered 80% after deductible Up to 24 visits per calendar year Check with your HMO Durable medical equipment Covered 100% Covered 80% of approved amount Covered, check with your HMO Prosthetic and orthotic appliances Covered 100% Covered 80% of approved amount Covered, check with your HMO On-line Tobacco Cessation counseling No charge Not covered Covered, check with your HMO Private duty nursing Covered 80% after deductible Check with your HMO Wig, wig stand, adhesives Upon meeting medical conditions, eligible for a lifetime maximum reimbursement of $300. (Additional wigs covered for children due to growth). Check with your HMO Hearing Care Exam Covered, $20 co-pay Covered 80% after deductible Check with your HMO Hearing aids2 Covered Not covered Check with your HMO M e n t a l H e a l t h / S u b s t a n c e A x x x x State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Mental Health Benefits -Inpatient Covered 100% up to 365 days per year 3 Covered 50% up to 365 days per year Check with your HMO; Inpatient services subject to deductible. Mental Health Benefits – Outpatient As necessary 90% of network rates 10% co-pay As necessary 50% of network rates Check with your HMO Alcohol & Chemical Dependency Benefits –Inpatient Covered 100% 4 Halfway House 100% Covered 50% 4 Halfway House 50% Check with your HMO; Inpatient services subject to deductible. Alcohol & Chemical Dependency Benefits -Outpatient $3,500 per calendar year5 90% of network rates 10% co-pay $3,500 per calendar year550% of network rates Check with your HMO 2 Deluxe hearing aids are covered at the same rate as basic hearing aids with the member paying the remainder. Discount hearing aids are offered through the XXX XXX. 0 Xxxxxxxxx days may be utilized for partial day hospitalization (PHP) at 2:1 ratio. One inpatient day equals two PHP days.

Labor Management Healthcare Committee. The Union shall be entitled to continue to participate in statewide Labor Management Healthcare Committee meetings. Article 24, Appendix K-2 HEALTH INSURANCE BENEFIT CHART P r Pre v entiv e v e n t i v e S e r Ser v i c e s ces State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Health maintenance exam Covered 100% 1 per year Not Covered Covered 100% Annual gynecological exam Covered 100% 1 per calendar year Not Covered Covered 100% Pap smear screening – laboratory services only 1 Covered 100% 1 per year Not Covered Covered 100% Well-baby and child care Covered 100% Not Covered Covered 100% Immunizations, annual flu shot & Hepatitis C screening for those at risk Covered 100% Not Covered Covered 100% Childhood Immunizations Covered 100% through age 16 Covered 80% Covered 100% Fecal occult blood screening 1 Covered 100% Not Covered Covered 100% Flexible sigmoidoscopy 1 Covered 100% Not Covered Covered 100% Prostate specific antigen screening 1 Covered 100% one per year Not Covered Covered 100% Mammography, annual standard film or mammography screening (covers digital mammography screening up to the standard film rate) 1 Covered 100% Covered 80% after deductible Covered 100% Colonoscopy 1 Covered 100% Covered 80% after deductible Covered 100% 1 Patient Protection and Affordable Care Act (PPACA) American Cancer Society guidelines apply P h Ph y s i c i a ic ia n O f f i c e S e r Office Ser v i c e s ices State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Office visits, consultations and urgent care visits Covered, $20 co-pay Covered 80% after deductible Covered, $20 co-pay Outpatient and home visits Covered 90% after deductible Covered 80% after deductible Covered, $20 co-pay E m e r g e n c y ncy M e d i c a di ca l C a r e Care State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Hospital emergency room for medical emergency or accidental injury Covered, $200 co-pay if not admitted Covered, $200 co- pay if not admitted Ambulance services – medically necessary Covered, 90% after deductible Covered, 100% after deductible D i a g n o s t Diagnost i c S e r Ser v i c e s ic es State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Laboratory and pathology tests Covered 90% after deductible Covered 80% after deductible Covered 100% Diagnostic tests and x-rays Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Radiation therapy Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible M a t e r n i t Maternit y S e r Ser v i c e s ic es Includes care by a certified nurse midwife (State Health Plan PPO only) State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Prenatal care Covered 100% Covered 80% after deductible Covered 100% Postnatal care Covered 90% after deductible Covered 80% after deductible Covered, $20 co-pay Delivery and nursery care Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible H o s p i t a l C a r e Hospital Care State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Semi-private room, inpatient physician care, general nursing care, hospital services and supplies Covered 90% after deductible, unlimited days Covered 80% after deductible, unlimited days Covered 100% after deductible Unlimited days Inpatient consultations Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Self-donated blood storage prior to surgery Covered 90% after deductible Covered 80% after deductible Check with your HMO Chemotherapy Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible A l t e r n a t i v e s t o H o s p i t a l C a r e Alternativ es to Hospital Care State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Skilled nursing care up to 120 days per confinement Covered 90% after deductible Covered 100% after deductible Hospice care Covered 100% Limited to the lifetime dollar maximum that is adjusted annually by the State Covered 100% after deductible Home health care Covered 90% after deductible, unlimited visits Check with your HMO S u r g i c a l S e r Surg ical Ser v i c e s ces State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Surgery—includes related surgical services. Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Male Voluntary sterilization Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Female Voluntary sterilization Covered 100% Covered 80% after deductible Covered 100% H u m a n Human O r g a n a n d T i s s u e gan and Tissue T r a n s p l a n ansplan t s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Liver, heart, lung, pancreas, and other specified organ transplants Covered 100% In designated facilities only. Up to $1 million lifetime maximum for each organ transplant Covered 100% after deductible in designated facilities Bone marrow—specific criteria apply Covered 100% after deductible in designated facilities Covered 100% after deductible in designated facilities Kidney, cornea, and skin Covered 90% after deductible in designated facilities Covered 80% after deductible Covered 100% after deductible subject to medical criteria O t h e r S e Other Se r v i c e s ices State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Allergy testing and therapy (non- injection) Covered 90% after deductible Covered 80% after deductible Covered,100% after deductible. Allergy injections Covered 90% after deductible Covered 80% after deductible Covered 100% Acupuncture Covered 80% after deductible if performed by or under the supervision of a M.D. or D.O. Check with your HMO Rabies treatment after initial emergency room visit Covered 90% after deductible Covered 80% after deductible Office visits: $20 co- pay. Injections: Covered 100% Autism Spectrum Disorder Applied Behavioral Analysis (ABA) treatment Covered 90% after deductible Covered 80% after deductible Covered,100% after deductible Chiropractic/spinal manipulation Covered, $20 co-pay Up to 24 visits per calendar year Covered 80% after deductible Up to 24 visits per calendar year Check with your HMO Durable medical equipment Covered 100% Covered 80% of approved amount Covered, check with your HMO Prosthetic and orthotic appliances Covered 100% Covered 80% of approved amount Covered, check with your HMO On-line Tobacco Cessation counseling No charge Not covered Covered, check with your HMO Private duty nursing Covered 80% after deductible Check with your HMO Wig, wig stand, adhesives Upon meeting medical conditions, eligible for a lifetime maximum reimbursement of $300. (Additional wigs covered for children due to growth). Check with your HMO Hearing Care Exam Covered, $20 co-pay Covered 80% after deductible Check with your HMO Hearing aids2 Covered Not covered Check with your HMO M e n t a l H e a l t h / S u b s t a n c e A x x x x Mental Health/Substance Abuse State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Mental Health Benefits -Inpatient Covered 100% up to 365 days per year 3 Covered 50% up to 365 days per year Check with your HMO; Inpatient services subject to deductible. Mental Health Benefits – Outpatient As necessary 90% of network rates 10% co-pay As necessary 50% of network rates Check with your HMO Alcohol & Chemical Dependency Benefits –Inpatient Covered 100% 4 Halfway House 100% Covered 50% 4 Halfway House 50% Check with your HMO; Inpatient services subject to deductible. Alcohol & Chemical Dependency Benefits -Outpatient $3,500 per calendar year5 90% of network rates 10% co-pay $3,500 per calendar year550% of network rates Check with your HMO 2 Deluxe hearing aids are covered at the same rate as basic hearing aids with the member paying the remainder. Discount hearing aids are offered through the XXX XXX. 0 Xxxxxxxxx days may be utilized for partial day hospitalization (PHP) at 2:1 ratio. One inpatient day equals two PHP days.

Labor Management Healthcare Committee. The Union shall be entitled to continue to participate in statewide Labor Management Healthcare Committee meetings. Article 24, Appendix K-2 HEALTH INSURANCE BENEFIT CHART P r e v e n t i v e S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Health maintenance exam Covered 100% 1 per year Not Covered Covered 100% Annual gynecological exam Covered 100% 1 per calendar year Not Covered Covered 100% Pap smear screening – laboratory services only 1 Covered 100% 1 per year Not Covered Covered 100% Well-baby and child care Covered 100% Not Covered Covered 100% Immunizations, annual flu shot & Hepatitis C screening for those at risk Covered 100% Not Covered Covered 100% Childhood Immunizations Covered 100% through age 16 Covered 80% Covered 100% Fecal occult blood screening 1 Covered 100% Not Covered Covered 100% Flexible sigmoidoscopy 1 Covered 100% Not Covered Covered 100% Prostate specific antigen screening 1 Covered 100% one per year Not Covered Covered 100% Mammography, annual standard film or digital mammography screening 1 Covered 100% Covered 80% after deductible Covered 100% Colonoscopy 1 Covered 100% Covered 80% after deductible Covered 100% 1 Patient Protection and Affordable Care Act (PPACA) guidelines apply P h y s i c i a n O f f i c e S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Office visits, , including telehealth via the provider’s tool, consultations and urgent care visits Covered, $20 co-pay Covered 80% after deductible Covered, $20 co-pay Outpatient and home visits Covered 90% after deductible Covered 80% after deductible Covered, $20 co-pay Telemedicine 2 via the carrier’s online tool – through 12/31/2022 Covered $10 co-pay Not covered Covered $10 co-pay Telemedicine 2 via the carrier’s online tool – Effective 1/1/2023 Covered 100% Not covered Covered, $10 co-pay E m e r g e n c y M e d i c a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Hospital emergency room for medical emergency or accidental injury Covered, $200 co-pay if not admitted Covered, $200 co- pay if not admitted Ambulance services – medically necessary Covered, 90% after deductible Covered, 100% after deductible D i a g n o s t i c S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Laboratory and pathology tests Covered 90% after deductible Covered 80% after deductible Covered 100% Diagnostic tests and x-rays Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Radiation therapy Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible M a t e r n i t y S e r v i c e s Includes care by a certified nurse midwife (State Health Plan PPO only) State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Prenatal care Covered 100% Covered 80% after deductible Covered 100% Postnatal care Covered 90% after deductible Covered 80% after deductible Covered, $20 co-pay Delivery and nursery care Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible 2 Effective 1/1/2023 – Telemedicine/Telehealth via Blue Cross's online vendor applies for Medical and Behavioral Health in-network services for the SHP PPO and will be covered 100%. $10 co-pay for Telemedicine via an HMO's online vendor applies to both Medical and Behavioral Health (if available through the carrier). H o s p i t a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Semi-private room, inpatient physician care, general nursing care, hospital services and supplies Covered 90% after deductible, unlimited days Covered 80% after deductible, unlimited days Covered 100% after deductible Unlimited days Inpatient consultations Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Self-donated blood storage prior to surgery Covered 90% after deductible Covered 80% after deductible Check with your HMO Chemotherapy Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible A l t e r n a t i v e s t o H o s p i t a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Skilled nursing care up to 120 days per confinement Covered 90% after deductible Covered 100% after deductible Hospice care Covered 100% Limited to the lifetime dollar maximum that is adjusted annually by the State Covered 100% after deductible Home health care Covered 90% after deductible, unlimited visits Check with your HMO S u r g i c a l S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Surgery—includes related surgical services. Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Male Voluntary sterilization – through 12/31/2022 Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Male Voluntary sterilization – effective 1/1/2023 Covered 100% Covered 80% after deductible Covered 100% after deductible Female Voluntary sterilization Covered 100% Covered 80% after deductible Covered 100% H u m a n O r g a n a n d T i s s u e T r a n s p l a n t s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Liver, heart, lung, pancreas, and other specified organ transplants Covered 100% In designated facilities only. Up to $1 million lifetime maximum for each organ transplant Covered 100% after deductible in designated facilities Bone marrow—specific criteria apply Covered 100% after deductible in designated facilities Covered 100% after deductible in designated facilities Kidney, cornea, and skin Covered 90% after deductible in designated facilities Covered 80% after deductible Covered 100% after deductible subject to medical criteria O t h e r S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Allergy testing and therapy (non- injection) Covered 90% after deductible Covered 80% after deductible Covered,100% after deductible. Allergy injections Covered 90% after deductible Covered 80% after deductible Covered 100% Acupuncture Covered 80% after deductible if performed by or under the supervision of a M.D. or D.O. Check with your HMO Rabies treatment after initial emergency room visit Covered 90% after deductible Covered 80% after deductible Office visits: $20 co- pay. Injections: Covered 100% Autism Spectrum Disorder Applied Behavioral Analysis (ABA) treatment Covered 90% after deductible Covered 80% after deductible Covered,100% after deductible Chiropractic/spinal manipulation Covered, $20 co-pay Up to 24 visits per calendar year Covered 80% after deductible Up to 24 visits per calendar year Check with your HMO Durable medical equipment Covered 100% Covered 80% of approved amount Covered, check with your HMO Prosthetic and orthotic appliances Covered 100% Covered 80% of approved amount Covered, check with your HMO On-line Tobacco Cessation counseling No charge Not covered Covered, check with your HMO Private duty nursing Covered 80% after deductible Check with your HMO Wig, wig stand, adhesives Upon meeting medical conditions, eligible for a lifetime maximum reimbursement of $300. (Additional wigs covered for children due to growth). Check with your HMO Hearing Care Exam Covered, $20 co-pay Covered 80% after deductible Check with your HMO Hearing aids2 aids 3 Covered Not covered Check with your HMO 3 Deluxe hearing aids are covered at the same rate as basic hearing aids with the member paying the remainder. Discount hearing aids are offered through the SHP PPO. M e n t a l H e a l t h / S u b s t a n c e A x x x x State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Mental Health Benefits -Inpatient Covered 100% up to 365 days per year 3 4 Covered 50% up to 365 days per year Check with your HMO; Inpatient services subject to deductible. Mental Health Benefits – Outpatient As necessary 90% of network rates 10% co-pay As necessary 50% of network rates Check with your HMO Alcohol & Chemical Dependency Benefits –Inpatient Covered 100% 4 5 Halfway House 100% Covered 50% 4 5 Halfway House 50% Check with your HMO; Inpatient services subject to deductible. Alcohol & Chemical Dependency Benefits -Outpatient $3,500 per calendar year5 90% of network rates 10% co-pay $3,500 per calendar year55050% of network rates Check with your HMO 2 Deluxe hearing aids are covered at the same rate as basic hearing aids with the member paying the remainder. Discount hearing aids are offered Office visits, including Telehealth through the XXX XXX. 0 Xxxxxxxxx provider’s online tool 6 Lesser of 10% of network rates or $10 co-pay As necessary 50% of network rates Check with your HMO Telehealth visits via the carrier’s online tool through 12/31/22 Lesser of 10% of network rates or $10 co-pay Not Covered $10 co-pay where available Office visits, including Telehealth through the carrier’s online tool 6– Effective 1/1/2023 Covered 100% Not Covered $10 co-pay where available 4 Inpatient days may be utilized for partial day hospitalization (PHP) at 2:1 ratio. One inpatient day equals two PHP days.

Labor Management Healthcare Committee. The Union shall be entitled to continue to participate in statewide Labor Management Healthcare Committee meetings. Article 24, Appendix K-2 HEALTH INSURANCE BENEFIT CHART P r e v e n t i v e S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Health maintenance exam Covered 100% 1 per year Not Covered Covered 100% Annual gynecological exam Covered 100% 1 per calendar year Not Covered Covered 100% Pap smear screening – laboratory services only 1 Covered 100% 1 per year Not Covered Covered 100% Well-baby and child care Covered 100% Not Covered Covered 100% Immunizations, annual flu shot & Hepatitis C screening for those at risk Covered 100% Not Covered Covered 100% Childhood Immunizations Covered 100% through age 16 Covered 80% Covered 100% Fecal occult blood screening 1 Covered 100% Not Covered Covered 100% Flexible sigmoidoscopy 1 Covered 100% Not Covered Covered 100% Prostate specific antigen screening 1 Covered 100% one per year Not Covered Covered 100% Mammography, annual standard film or mammography screening (covers digital mammography screening up to the standard film rate) 1 Covered 100% Covered 80% after deductible Covered 100% Colonoscopy 1 Covered 100% Covered 80% after deductible Covered 100% 1 Patient Protection and Affordable Care Act (PPACA) American Cancer Society guidelines apply P h y s i c i a n O f f i c e S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Office visits, consultations and urgent care visits Covered, $20 co-pay Covered 80% after deductible Covered, $20 co-pay Outpatient and home visits Covered 90% after deductible Covered 80% after deductible Covered, $20 co-pay E m e r g e n c y M e d i c a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Hospital emergency room for medical emergency or accidental injury Covered, $200 co-pay if not admitted Covered, $200 co- pay if not admitted Ambulance services – medically necessary Covered, 90% after deductible Covered, 100% after deductible D i a g n o s t i c S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Laboratory and pathology tests Covered 90% after deductible Covered 80% after deductible Covered 100% Diagnostic tests and x-rays Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Radiation therapy Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible M a t e r n i t y S e r v i c e s Includes care by a certified nurse midwife (State Health Plan PPO only) State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Prenatal care Covered 100% Covered 80% after deductible Covered 100% Postnatal care Covered 90% after deductible Covered 80% after deductible Covered, $20 co-pay Delivery and nursery care Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible H o s p i t a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Semi-private room, inpatient physician care, general nursing care, hospital services and supplies Covered 90% after deductible, unlimited days Covered 80% after deductible, unlimited days Covered 100% after deductible Unlimited days Inpatient consultations Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Self-donated blood storage prior to surgery Covered 90% after deductible Covered 80% after deductible Check with your HMO Chemotherapy Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible A l t e r n a t i v e s t o H o s p i t a l C a r e State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Skilled nursing care up to 120 days per confinement Covered 90% after deductible Covered 100% after deductible Hospice care Covered 100% Limited to the lifetime dollar maximum that is adjusted annually by the State Covered 100% after deductible Home health care Covered 90% after deductible, unlimited visits Check with your HMO S u r g i c a l S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Surgery—includes related surgical services. Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Male Voluntary sterilization Covered 90% after deductible Covered 80% after deductible Covered 100% after deductible Female Voluntary sterilization Covered 100% Covered 80% after deductible Covered 100% H u m a n O r g a n a n d T i s s u e T r a n s p l a n t s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Liver, heart, lung, pancreas, and other specified organ transplants Covered 100% In designated facilities only. Up to $1 million lifetime maximum for each organ transplant Covered 100% after deductible in designated facilities Bone marrow—specific criteria apply Covered 100% after deductible in designated facilities Covered 100% after deductible in designated facilities Kidney, cornea, and skin Covered 90% after deductible in designated facilities Covered 80% after deductible Covered 100% after deductible subject to medical criteria O t h e r S e r v i c e s State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Allergy testing and therapy (non- injection) Covered 90% after deductible Covered 80% after deductible Covered,100% after deductible. Allergy injections Covered 90% after deductible Covered 80% after deductible Covered 100% Acupuncture Covered 80% after deductible if performed by or under the supervision of a M.D. or D.O. Check with your HMO Rabies treatment after initial emergency room visit Covered 90% after deductible Covered 80% after deductible Office visits: $20 co- pay. Injections: Covered 100% Autism Spectrum Disorder Applied Behavioral Analysis (ABA) treatment Covered 90% after deductible Covered 80% after deductible Covered,100% after deductible Chiropractic/spinal manipulation Covered, $20 co-pay Up to 24 visits per calendar year Covered 80% after deductible Up to 24 visits per calendar year Check with your HMO Durable medical equipment Covered 100% Covered 80% of approved amount Covered, check with your HMO Prosthetic and orthotic appliances Covered 100% Covered 80% of approved amount Covered, check with your HMO On-line Tobacco Cessation counseling No charge Not covered Covered, check with your HMO Private duty nursing Covered 80% after deductible Check with your HMO Wig, wig stand, adhesives Upon meeting medical conditions, eligible for a lifetime maximum reimbursement of $300. (Additional wigs covered for children due to growth). Check with your HMO Hearing Care Exam Covered, $20 co-pay Covered 80% after deductible Check with your HMO Hearing aids2 Covered Not covered Check with your HMO M e n t a l H e a l t h / S u b s t a n c e A x x x x State Health Plan PPO “SHP – PPO” Benefits HMO Plan “HMO” Benefits In-network Out-of-network Mental Health Benefits -Inpatient Covered 100% up to 365 days per year 3 Covered 50% up to 365 days per year Check with your HMO; Inpatient services subject to deductible. Mental Health Benefits – Outpatient As necessary 90% of network rates 10% co-pay As necessary 50% of network rates Check with your HMO Alcohol & Chemical Dependency Benefits –Inpatient Covered 100% 4 Halfway House 100% Covered 50% 4 Halfway House 50% Check with your HMO; Inpatient services subject to deductible. Alcohol & Chemical Dependency Benefits -Outpatient $3,500 per calendar year5 year 90% of network rates 10% co-pay 5 $3,500 per calendar year550year 50% of network rates 5 Check with your HMO 2 Deluxe hearing aids are covered at the same rate as basic hearing aids with the member paying the remainder. Discount hearing aids are offered through the XXX XXX. 0 Xxxxxxxxx days may be utilized for partial day hospitalization (PHP) at 2:1 ratio. One inpatient day equals two PHP days.