Common use of Coverage for Clause in Contracts

Coverage for. Single/Family | Plan Type: HMO Common Medical Event Services You May Need Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider Your Cost If You Use A(n) Out-of-Network Provider Limitations & Exclusions If you need help recovering orhave other special health needs Durable medical equipment Covered in full. Not covered. Subject to Medicare part B Guidelines. Hospice service 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Eye exam Covered in full. Not covered. Limited to one (1) routine vision exam every twelve (12) months. Glasses Not covered. Not covered. –––––––––––none––––––––––– Dental check-up Not covered. Not covered. –––––––––––none––––––––––– Coverage for: Single/Family | Plan Type: HMO Services Your Plan Does NOT cover (This isn't a complete list. Check your policy or plan document for other excluded services.) • Acupuncture • Dental care (Adult) • Prescription Drugs • Weight loss programs • Bariatric Surgery • Long-term care • Private-duty nursing • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Routine foot care • Chiropractic care • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatment

Coverage for. Single/Family | Plan Type: HMO Common Medical Event Services You May Need Your Cost If You Use A(n) Paramount Ohio HMO Network. Provider Your Cost If You Use A(n) Out-of-Network Provider Limitations & Exclusions If you need help recovering orhave other special health needs Durable medical equipment Covered in full. Not covered. Subject to Medicare part B Guidelines. Hospice service 15% Co-Insurance. Not covered. –––––––––––none––––––––––– If your child needs dental or eye care Eye exam Covered in full. Not covered. Limited to one (1) routine vision exam every twelve (12) months. Glasses Not covered. Not covered. –––––––––––none––––––––––– Dental check-up Not covered. Not covered. –––––––––––none––––––––––– Coverage for: Single/Family | Plan Type: HMO Services Your Plan Does NOT cover (This isn't a complete list. Check your policy or plan document for other excluded services.) • Acupuncture • Dental care (Adult) • Prescription Drugs • Weight loss programs • Bariatric Surgery • Long-term care • Private-duty nursing • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Routine foot care • Chiropractic care • Routine eye care (Adult) • Hearing Aids ($700 toward the purchase of hearing aid(s) every 36 months) • Infertility treatmenttreatment If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. 53 For more information on your rights to continue coverage, contact the plan at ▇-▇▇▇-▇▇▇-▇▇▇▇. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at ▇-▇▇▇-▇▇▇-▇▇▇▇ or ▇▇▇.▇▇▇.▇▇▇/▇▇▇▇, or the U.S. Department of Health and Human Services at ▇-▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇▇▇▇ or ▇▇▇.▇▇▇▇▇.▇▇▇.▇▇▇.