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Providence Health Plan is a health plan with a Medicare contract. - page 25 / 32

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INTRODUCTION This section of your Summary of Benefits was created to help explain your benefits further. The information that is in this section is additional information that is not found in the earlier sections. At Providence Health Plans, our goal is to know you, care for you and help ease your way. Thank you for being a member of Providence Medicare Advantage Plans.

IN-NETWORK As a member of Providence Medicare Extra + RX there is a network (group of providers) that Providence has contracted with to provide you care. These are called in-network providers.

OUT-OF-POCKET MAXIMUM With Providence Medicare Extra + RX there is an out-of-pocket maximum. This means that $2,500 is the maximum amount you will pay for services. This applies to a combination of both in-network and out of network services that are Medicare covered. This out-of-pocket applies to your authorized medical Medicare covered services only.

WILL SOME SERVICES REQUIRE A PRIOR AUTHORIZATION? Yes. To receive coverage, the following services require prior authorization for all: Inpatient hospital (including maternity) admissions Skilled Nursing Facility (SNF) admissions Inpatient Rehabilitation Facility admissions Mental Health and/or Chemical Dependency services contact authorizing agent PBH/UBH tel: 1-800-711-4577

Non-emergency procedures, including, but not limited to, the following categories: Miscellaneous cosmetic, reconstructive, nasal, oral/dental/orthodontic procedures Cervical, thoracic and lumbar spinal surgeries Bariatric surgery Organ/tissue and bone marrow transplants (including pre-transplant evaluations and HLA typing) Uvulectomy, uvulopalatophyaryngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP) Services and procedures without specific CPT codes (unlisted services and procedures) Procedures, surgeries/treatment that may be considered experimental or investigational Genetic testing/cytogenetic studies/counseling Pulmonary Rehabilitation Cardiac Rehabilitation High Tech Diagnostic Imaging: MRI, MRA, SPECT, CT, CTA, PET, Nuclear Cardiology Authorizing agent: American Imaging Management (AIM) General anesthesia for dental services Neuropsychological Testing Durable Medical Equipment over $1500.00, per line item. In-plan authorizing agent Providence Home Services at 1-888-882-4164 or fax to 503-215-4655

Call to request prior authorization at 503-574-6400 or 1-800-638-0449 or fax to 503-574-6464 or 1-800-989-7479.

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