NHP HMO */** F*CG Mod V $**/$**/**%/$*,****

***-***** ****** ******** ***********

F0CG Mod V

$15/$30/20%/$1,000

W/Direct Access Rider

NEIGHBORHOOD HEALTH PARTNERSHIP

HMO

SUMMARY OF BENEFITS

A quick glance at this Summary of Benefits will introduce you to the important advantages of Neighborhood Health Partnership (NHP), a Florida HMO. The Summary of Benefits, although a helpful tool, is only a summary. Always refer to your Handbook for a fuller explanation of your coverage or call Customer Services at the phone numbers on your NHP ID Card when you have a question about your plan. In the event of a conflict between this Summary of Benefits and the Handbook, the Handbook will control. Services must be provided by health care providers which have contracts with NHP, referred to as "Plan Providers," "Plan Physicians" or "Plan Hospitals," unless in an Emergency or with prior authorization by NHP.

Features Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise specified. You are also responsible for any copayments and/or coinsurance listed below.

Deductible $1,000 per member, and/or $2,000 per family, whichever comes first. Individual deductible amounts will count toward the family deductible. However, an individual will not have to pay more than the individual deductible amount.

Any deductible is on a calendar year basis.

Coinsurance Benefits as defined below may be subject to a coinsurance of 20% once the calendar year deductible is met.

Out of Pocket

Maximum

The limit which you and your eligible family members must pay in copayments (including Pharmacy Copayments) and coinsurance per calendar year is $3,000 per member and $6,000 per family. Individual Out of Pocket Maximum amounts will count toward the family Out of Pocket Maximum. However, an individual will not have to pay more than the individual Out of Pocket Maximum amount. Out of Pocket Maximum includes the Deductible.

Out of Pocket Maximum includes amounts paid toward Pharmacy coinsurance.

Copayments Primary Care Physician (PCP)

(Office Visit)

$15 copayment per visit

Specialist (Office Visit) $30 copayment per visit

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NHP HMO 1/14 F0CG Mod V $15/$30/20%/$1,000

Urgent Care Center $75 copayment per visit

Emergency Room $125 copayment per visit

Outpatient Therapy 20% after deductible

Inpatient Hospital 20% after deductible

Radiology No copayment for minor

diagnostics; 0% per service after

deductible for major diagnostics

including CT, MRI, MRA, PET

scans and nuclear imaging.

Allergy Testing $15 copayment per visit

Primary Care Your PCP is responsible for coordinating all your health care services, including referrals to Specialists. Your PCP or Physician Specialist must obtain Pre-Authorization for designated services including, but not limited to, all inpatient care, outpatient surgical procedures, durable medical equipment (DME), home health services, home infusion, hospice care, rehabilitation, skilled nursing facility, and transplant services.

Referrals Your PCP is responsible for coordinating all referrals to specialists, except for the following specialties which you may access directly:

• Podiatry.

• Chiropractic

• Dermatology (5 visits per calendar year). Additional visits require referrals

• Gynecology

Services that must be

provided by NHP’s

behavioral health

network.

• Substance Use Disorders.

• Neurobiological Disorder Services – Autism Spectrum Disorder.

• Mental Health Services

Note: If your Employer purchased a Direct Access Rider, you may see a Specialist without a referral from your PCP. Please refer to your NHP ID Card or call Customer Services to verify the need to obtain a referral to a Specialist. Even when the Plan includes a Direct Access Rider, you must select a PCP or NHP will assign one to you. If you need assístance, call Customer Services.

Prescription Drugs If your Employer has elected to provide coverage for prescription drugs, you will receive a copy of a Prescription Drug Rider which explains your prescription drug coverage.

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NHP HMO 1/14 F0CG Mod V $15/$30/20%/$1,000

YOUR NHP PLAN COVERAGE

IMPORTANT NOTICE: Unless otherwise stated, care, services or treatment not managed by your Primary Care Physician, not Medically Necessary, or not pre- certified by NHP are not Covered Services. Services must be provided by Plan Providers, except when prior authorized or in the case of an Emergency Medical Condition.

You must check your Handbook for further details relating to your coverage.

Services & Supplies Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise specified. You are also responsible for any copayments and/or coinsurance listed below.

Ambulance 20% after deductible in emergency situations or when authorized by NHP to transfer you to a NHP facility.

Applied Behavioral

Analysis (Services must

be provided by NHP's

behavioral health

network)

Outpatient: $15 copayment

PCP referral not required

Inpatient:

20% after deductible

Autism Spectrum

Disorder

Covered as any other eligible service, based on place of service. Bones or joints of the

jaw and facial region

Covered as any other eligible service, based on place of service. Chiropractic Services $15 copayment per visit

Limited to 20 treatments per calendar year; PCP referral not required. Dermatology $30 copayment per visit

PCP referral not required for 5 visits per calendar year; further visits require PCP referral.

Diabetes $30 copayment per visit

Services include outpatient self-management training and educational services.

Durable Medical

Equipment (DME) and

disposable medical

supplies, including

breast pumps

20% after deductible

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NHP HMO 1/14 F0CG Mod V $15/$30/20%/$1,000

Services & Supplies Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise specified. You are also responsible for any copayments and/or coinsurance listed below.

This benefit category contains services/devices that may be Essential or non-Essential Health Benefits as defined by the Patient Protection and Affordable Care Act depending upon the service or device delivered. A benefit review will take place once the dollar limit is exceeded. If the service/device is determined to be rehabilitative or habilitative in nature, it is an Essential Health Benefit and will be paid. If the benefit/device is determined to be non-essential, the maximum will have been met and the claim will not be paid.

Emergency Room

Services

$125 copayment per visit

Any deductible and/or copayment for the emergency room is waived if the patient is admitted to the hospital.

Enteral Formula 20% after deductible

For the treatment of inherited diseases of amino acid, organic acid, carbohydrate, or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein, for individuals, through the age of 24. Family Planning Covered as any other eligible service, based on place of service. Limited to surgical sterilization, implantable contraceptives and intrauterine birth control devices.

Gynecology $30 copayment per visit

PCP referral is not required.

Hearing Aids 20% after deductible

Limited to $2,500 per year and to a single purchase (including repair/replacement) every three years.

Hearing Exams

(children through age

21)

No copayment when performed by PCP to determine need for hearing correction. Limited to one exam per calendar year. Deductible does not apply.

Home Health Services 20% after deductible

Limited to 60 visits per calendar year not to exceed 60 visits per spell of Illness. Custodial care is not covered.

Home Infusion Services 20% after deductible

Limited to 60 visits per calendar year not to exceed 60 visits per spell of Illness.

Hospice Care 20% after deductible

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NHP HMO 1/14 F0CG Mod V $15/$30/20%/$1,000

Services & Supplies Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise specified. You are also responsible for any copayments and/or coinsurance listed below.

Hospital Facility Care Inpatient:

20% after deductible

Outpatient Facility - Surgical Procedures:

20% after deductible

Outpatient Facility - Non-Surgical Procedures:

20% after deductible

Minor Diagnostic/X-Ray 0%. Deductible does not apply. Major Diagnostic

Services, including CT,

MRI, MRA, PET Scans

and Nuclear Imaging

0% after deductible

Mammography

Screening

No copayment and not subject to any deductible.

Mastectomy Covered as any other eligible service, based on place of service. Maternity Care,

including pre- and post-

natal care and delivery*

Physician Office

Services include one

OB ultrasound between

weeks 13 and 24 of

pregnancy.

Covered as any other eligible service, based on place of service. Note: any office visit copayment applies only to the initial visit. Mental Health

(Services must be

provided by NHP’s

behavioral health

network)

Outpatient: $15 copayment

PCP referral not required

Inpatient:

20% after deductible

Neurobiological

Disorder Services –

Autism Spectrum

Disorder

Outpatient: $15 copayment

PCP referral not required

Inpatient:

20% after deductible

Newborn Children*

(birth – 30 days)

Covered as any other eligible service, based on place of service. Organ Transplant

Inpatient Services

Covered as any other eligible service, based on place of service. Must be prior authorized by NHP Medical Director or designee. 6

NHP HMO 1/14 F0CG Mod V $15/$30/20%/$1,000

Services & Supplies Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise specified. You are also responsible for any copayments and/or coinsurance listed below.

Osteoporosis Covered as any other eligible service, based on place of service. Limited to diagnosis and treatment of high-risk individuals. Outpatient Therapies,

including Habilitative

Services

20% after deductible

Limited to 20 visits per calendar year per modality except 36 visits for cardiac therapy.

Physical Rehabilitation

– Inpatient Care

20% after deductible

Limited to 60 days per calendar year for restorative physical therapy. Physician Services 20% after deductible for inpatient care or outpatient surgical services when peformed in an Inpatient setting or an Outpatient Facility. Podiatry $15 copayment per visit

PCP referral not required.

Preventive Health

Services

No Copayment and not subject to any Deductible.

Primary Care Physician

(PCP)

$15 copayment per visit

Only applies to your designated PCP.

Prosthetic Devices 20% after deductible

Limited to one prosthetic per loss of limb or eye during the entire period of time you are covered.

Skilled Nursing Facility 20% after deductible

Limited to 120 days per calendar year not to exceed 120 visits per spell of Illness; custodial care is not covered.

Specialist Office Visits $30 copayment per visit

PCP referral required except as noted above.

Sterilization Covered as any other eligible service, based on place of service. Reversals are not covered.

Substance Use

Disorders

(Services must be

provided by NHP’s

behavioral health

network)

Outpatient:

$15 copayment

Inpatient:

20% after deductible

Urgent Care Center $75 copayment per visit

Vision Screening

(children through age

21)

No copayment when performed by PCP. Deductible does not apply. Limited to services necessary to determine need for vision correction and to one exam per calendar year.

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NHP HMO 1/14 F0CG Mod V $15/$30/20%/$1,000

* For coverage to begin at the date of birth for newborn children, a completed and signed enrollment form must be received by NHP. When received within 30 days of birth, no additional premium will be charged for this 30 day period. When notice is received within 60 days from the date of birth, premium will be charged from the date of birth. If the enrollment form is not received within 60 days of birth, the newborn child will be considered a Late Enrollee by NHP. You must enroll your newborn within these time periods regardless of whether your coverage is family coverage. Your Handbook has a description of benefits, including any limitations and exclusions. You have coverage for Prescription Drugs only if your Employer/Group has elected to obtain a Prescription Drug Rider.

7600 Corporate Center Drive, Miami, FL 33126 / PO Box 025680, Miami, FL 33102-5680 www.myNHP.com or call Customer Services at the phone number on your NHP ID Card. 8

DIRECT ACCESS RIDER

As of the Effective Date, and notwithstanding anything in the Group Service Agreement

(“Agreement”) to the contrary, the following Direct Access Rider is hereby made a part of the Agreement if elected by the Group and such election is evidenced in the Group’s Application for Group Service Agreement. The terms used in this Rider shall have the same meaning ascribed thereto or used in the Agreement, unless otherwise stated herein. DIRECT ACCESS PROGRAM

A Member with a Direct Access Rider has the right to elect to visit an NHP Specialist without a referral from the Primary Care Physician or Plan (“Direct Access Visit(s Direct Access Visits are subject to the terms and conditions of the Agreement and this Direct Access Rider. All services and treatment rendered to the Member by a NHP Specialist during or in connection with a Direct Access Visit are subject to NHP’s Utilization Review (UR) requirements and the Agreement, except as may be stated otherwise in this Rider. A Direct Access Visit includes services and treatment received from an NHP Specialist, so long as such services do not require pre-certification from NHP. Those services which require pre- certification under the Plan’s UR requirements require pre-certification on a Direct Access Visit.

NEIGHBORHOOD HEALTH PARTNERSHIP, INC.

Nicholas J. Zaffiris

CEO

South Florida Health Plans

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