PRIORITY HEALTH SUMMARY OF BENEFITS – STATE OF MICHIGAN

Effective 10/01/00

Physician Services

Office Visits & Consulting Specialists Visits: Covered in full. (All Specialists visits require a Primary Care Provider Referral)

Routine Physical Exam: Covered in full

Pre and Postnatal Care: Covered in full

Well Child Care: Covered in full

Immunizations: Covered in full

Allergy Care: Covered in full, including Injections and Serum

Routine Gynelogical Exam by your PCP: Covered in full

Office Surgical Procedures: Covered in full

Diagnostic Laboratory and X-ray: Covered in full

Chemotherapy: Covered in full

Podiatry Care: Covered in full. Routine foot care not covered.

Physical, Speech, Occupational, Pulmonary & Cardiac Therapy: Covered in full for up to 60 visits per contract year.

Outpatient Services

Outpatient Surgery: Covered in full

Diagnostic Laboratory & X-ray: Covered in full

Radiation Therapy: Covered in full

Hemodialysis: Covered in full

Physical, Speech, Occupational, Pulmonary & Cardiac Therapy: Covered in full for up to 60 visits per contract year.

Inpatient Hospital Services

Number of Days of Care: Unlimited Number of Days of Care as deemed medically/clinically necessary.

Semi-Private Room & Intensive Care: Covered in full

Surgery & All Related Surgical Services: Covered in full

Ancillary Services: Covered in full

Inpatient Professional Services: Covered in full

Human Organ Tissue Transplants: Covered in full

Emergency Medical Care

Hospital: Covered in full

Urgent Care Centers: Covered in full

Physician’s Office/Health Center: Covered in full

Ambulance: Covered in full

Note: Non-life threatening services must be pre-authorized by your Primary Care Provider.

Family Planning/Infertility Services

Vasectomy: Covered in full when performed in physician’s office

Tubal Ligation

Physician Services: Covered in full

Outpatient Facility Charges: Covered in full

Inpatient Facility Charges: Covered in full

Diaphragm: Covered with 50% copayment

Infertility Counseling & Treatment: Covered in full. Limitations and exclusions apply.

Mental Health Care

Inpatient: Covered in full for 45 days per contract year.

Outpatient: Covered in full for 20 visits per contract year.

Substance Abuse Care

Treatment for Alcohol and Drug Dependency covered in full. (Residential: 45 days, renews 60 days after discharge, Outpatient: 35 visits.)

NOTE: All mental health and substance abuse services must be arranged through Priority Health’s Behavioral Health Department.

Prescription Drugs

Covered with a $2 copayment. Includes contraceptive medications. Includes disposable needles and syringes for diabetics. Infertility prescriptions covered with a 50% copayment.

Miscellaneous

Durable Medical Equipment: Covered in full

Prosthetics & Orthotics/Support Devices: Covered in full. Limitations apply. (Shoe inserts not covered.)

Skilled Nursing Facility Care and Inpatient Rehabilitation Care: Covered in full up to 730 lifetime days.

Home Health Care: Covered in full. Intermittent skilled nursing visits covered in full. Home therapies (speech, physical, occupational, pulmonary and cardiac) covered in full. Limitations apply.

Custodial Care/Private Duty Nursing/Home Health Aides: Coverage not available

Vision Care: Covered for medical conditions and diseases of the eye. Eye exam and refraction’s, one per member every two-contract years.

Hearing Care: Covered for hearing exam and hearing aid (one per ear) once every 36 consecutive months.

TMJ: Covered with a 50% copayment. Limitations apply.

Dependent Children: Covered to end of the calendar year in which they turn 19. Full-time college students may be covered until they are no longer a full-time college student or turn 25, whichever is first. Over 25 if handicapped dependent.

Retiree Coverage: Coverage not available

Conversion: Conversion option available locally with Priority Health

Claim Forms: None

Benefit Maximum

No deductible, no lifetime maximums; unlimited services with no day/dollar limit except as noted. Benefits listed here are intended to be an easy-to-read summary of your coverage. A complete listing of benefits, limitations and exclusions is contained in your Certificate of Coverage, which is issued to all subscribers and available to prospective members upon request.

Priority Health Note: All services must be medically necessary and received from participating providers or other health professionals as approved or authorized by the member’s Primary Care Provider and, when required, certified in advance by the health plan.

This information is available in alternative accessible formats, upon request. For further information, please call our Customer Service Department at 616 942-1221 or 800 446-

5674. For TDD Service call 616 975-8485.

1231 East Beltline NE 442 Century Lane

Grand Rapids, MI 49425-4501 Holland, MI 49423-4295