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52 Attachment A: CoverKids Benefit Summary

BENEFIT FAMILY INCOME BETWEEN 150-250% FPL FAMILY INCOME AT OR BELOW 150% FPL Annual Deductible None None Preexisting Condition Requirement None None Physician Office Visit $15 copay PCP; $20 copay specialist $5 copay PCP or specialist Hospital Care $100 per admission (waived if readmitted within 48 hours for same episode) $5 per admission (waived if readmitted within 48 hours for same episode) Prescription Drug Coinsurance/Copay $5 generic; $20 preferred brand; $40 non- preferred brand $1 generic; $3 preferred brand; $5 non-preferred brand Maternity $15 copay OB, first visit only; $20 copay specialist; $100 hospital admission $5 copay OB or specialist, first visit only; $5 hospital admission Routine Health Assessment and Immunizations – Child No copays for services rendered under American Academy of Pediatrics guidelines No copays for services rendered under American Academy of Pediatrics guidelines Emergency Room $50 copay per use (waived if admitted) $5 copay per use in case of an emergency (waived if admitted); $10 copay per use for non-emergency Chiropractic Care $15 copay; Maintenance visits not covered when no additional progress is apparent or expected to occur $5 copay; Maintenance visits not covered when no additional progress is apparent or expected to occur Ambulance Service – Air & Ground No copay 100% of reasonable charges when deemed medically necessary by claims administrator No copay 100% of reasonable charges when deemed medically necessary by claims administrator Lab and X-ray No copay 100% benefit No copay 100% benefit Physical, Speech & Occupational Therapy $15 copay per visit; Limited to 52 visits per year per condition $5 copay per visit; Limited to 52 visits per year per condition