Schedule of benefits booklet

OSMA HEALTH
SCHEDULE OF BENEFITS BOOKLET
*Note: This high deductible option complies with the requirements for a Health Savings Account (HSA),
but does not comply with the more rigid requirements for a Medical Savings Account (MSA)
We're delighted to present you with a copy of your schedule of benefits
booklet. Please keep this booklet with your plan document and summary
plan description

THE BENEFITS AND COVERAGES DESCRIBED HEREIN ARE PROVIDED THROUGH A TRUST
FUND ESTABLISHED BY A GROUP OF EMPLOYERS (OSMA HEALTH TRUST). THE TRUST
FUND IS NOT SUBJECT TO ANY INSURANCE GUARANTY ASSOCIATION. OTHER RELATED
FINANCIAL INFORMATION IS AVAILABLE FROM YOUR EMPLOYER OR FROM THE OSMA
HEALTH AND WELFARE BENEFIT CORPORATION. EXCESS INSURANCE IS PROVIDED BY A
LICENSED INSURANCE COMPANY TO COVER CERTAIN CLAIMS WHICH EXCEED CERTAIN
AMOUNTS. THIS IS THE ONLY SOURCE OF FUNDING FOR THESE BENEFITS AND
COVERAGES. THE BENEFITS AND COVERAGES DESCRIBED HEREIN ARE FUNDED BY
CONTRIBUTIONS FROM EMPLOYERS, EMPLOYEES, AND OTHER INDIVIDUALS ELIGIBLE
FOR COVERAGE.
SCHEDULE OF BENEFITS BOOKLET

MEDICAL BENEFITS
All benefits listed in this schedule of benefits booklet are subject to all other provisions of the Plan as described in the
Plan Document, which is incorporated herein by reference. If you do not have the Plan Document, please contact
your Employer.

Please be advised that the exclusions and limitations in Part X of the Plan, include, but are not limited to, the Plan
Administrator's determination that care and treatment is not Medically Necessary, that charges are not within Allowable
Charges, and that services, supplies and care are Experimental and/or Investigational. The meanings of these capitalized
terms are in Part IX of the Plan.
Verification of Eligibility
Call the numbers listed below to verify eligibility for plan benefits. Verification is not binding. All benefits are subject to the
Plan's provisions at the time treatment is provided.
1.888.244.5096 or 405.290.5666
Post-service notification for all Hospital inpatient stays, Long Term Acute Care Facility stays, Skilled Nursing Facility
stays, Home Health Care and DME purchase or rental in excess of $1,000 is required within two working days of
services being rendered. Failure to comply may result in a reduction in reimbursement. Please see Part VIII, Cost
Management Services, of the Plan.
NETWORK PROVIDERS
The Plan has entered into agreements with certain Hospitals, Physicians and other health care providers called network
providers. These network providers have agreed to charge reduced fees so the Plan may reimburse a higher percentage of
their fees.
When a network provider is used, a higher level of benefit will be received than when a non-network provider is used.
Compare in-network to out-of-network in this schedule. It is the covered Person's choice on which provider to use.
A list of network providers will be given to Participants and updated as needed. Your PPO will be listed on your
identification card.
In-network benefits apply only to charges for services performed by providers actively participating in the network
on the date services were received. Not all providers at participating hospitals are in the network. You may have
some services during an episode of care, which are covered at the in-network level, and some services, provided by
non-network providers, covered at the out-of-network level. For example, if you have surgery at an in-network
hospital using a participating surgeon, your anesthesiology or pathology services may be from non-network providers.
If this happens, the anesthesiology and pathology services would be treated as out-of-network benefits.
DEDUCTIBLES/OUT-OF-POCKETS PAYABLE BY COVERED PERSONS

Deductibles and out-of-pockets are dollar amounts that the Covered Person must pay before the Plan pays.
A deductible is an amount of Covered Expenses for which no benefits will be paid. Before benefits can be paid in a Calendar
Year, a Covered Person must meet the deductible shown in this schedule. Each January 1, a new deductible amount is
required. Deductibles do not accrue toward the out-of-pocket maximum.
Out-of-pocket is an amount of money that is a percentage of the Allowable Charge that a Covered Person must pay for
certain services.
BENEFIT PAYMENT

Each Calendar Year, benefits will be paid for the Covered Expenses of a Covered Person that are in excess of the deductible.
Payment will be made at the rate shown under percentage payable in this schedule. No benefits will be paid in excess of the
maximum benefit amount or any listed limit.

OUT-OF-POCKET MAXIMUM
Covered Expenses are payable at the percentages shown each Calendar Year until the out-of-pocket maximum shown in this
schedule is reached. Then, Covered Expenses incurred by a Covered Person will be payable at 100% for the rest of the
Calendar Year, except for excluded charges.
MAXIMUM BENEFIT AMOUNT

The maximum benefit amount is shown in this schedule. It is the total amount of benefits that will be paid for all Covered
Expenses incurred by a Covered Person.
SCHEDULE OF BENEFITS
BENEFIT DESCRIPTION
IN-NETWORK
OUT-OF-NETWORK
Individual Medical Calendar Year Maximum1
$3,000,000
Individual Deductible Per Calendar Year
Out-of-pocket Maximum2
$2,000 $4,000
Deductible and Out-of-pocket
Deductibles and out-of-pocket apply to all services except as noted Charges for the following are not applied to meeting your out-of-pocket maximum and are never paid at 100%:
Proton beam therapy Orthotripsy
Durable Medical Equipment (DME) Genetic analysis
Prosthetics Electrical Stimulators
Other orthotics
Physician Services3
Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Physician Services provided in a Facility Deductible Applies:
Deductible Applies:
(Hospital visits, surgeon fees, anesthesia fees) 80% Allowable Charges paid by 60% Allowable Charges paid by Plan Covered Wellness Services
Not covered
Services mandated to be covered by the Patient Protection and Not covered
Services mandated to be covered by the Patient Protection and Hospital and Other Facility Charges3
Deductible Applies:
Deductible Applies:
Plan4
Outpatient Care: surgery, radiology, lab & pathology Deductible Applies:
Deductible Applies:
Plan4
Deductible Applies:
Deductible Applies:
Plan4
Deductible Applies:
Deductible Applies:
Plan4
Ambulance
Deductible Applies:
(emergency transport to nearest facility only)5 BENEFIT DESCRIPTION
IN-NETWORK
OUT-OF-NETWORK
Other Services
Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Plan4
Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Plan4
Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Outpatient OT, PT, speech, respiratory therapy, and cardiac rehab Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Spinal Manipulation, maximum 12 per Calendar Year Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Deductible Applies:
Deductible Applies:
Deductible Applies:
Deductible Applies
50% Allowable Charges paid by 50% Allowable Charges paid by Wig or other scalp prostheses after chemotherapy or radiation therapy Deductible Applies:
Deductible Applies:
80% Allowable Charges paid by 60% Allowable Charges paid by Deductible Applies:
Deductible Applies
50% Allowable Charges paid by 50% Allowable Charges paid by Deductible Applies:
Deductible Applies
50% Allowable Charges paid by 50% Allowable Charges paid by Plan BENEFIT DESCRIPTION
IN-NETWORK
OUT-OF-NETWORK
DME and Supplies
Deductible Applies:
Deductible Applies:
50% Allowable Charges paid by 50% Allowable Charges paid by Deductible Applies:
Deductible Applies:
50% Allowable Charges paid by 50% Allowable Charges paid by Other orthotics2
Deductible Applies:
Deductible Applies:
50% Allowable Charges paid by 50% Allowable Charges paid by Plan Wisdom Teeth Extraction
Deductible Applies:
Transplants
Deductible Applies:
Not covered
80% Allowable Charges paid by Plan Post-service Notification Penalty
Allowable Charges will be reduced 50% up to $1,000 after the calculation Outpatient Prescription Drug Benefit
Deductible Applies:
Deductible Applies:
Specialty Drug Benefit
Tier 16
Tier 26
Not covered
Benefits apply to Out- Benefits apply to Out- FOOTNOTES. See references in schedule.
1 The $3,000,000 Calendar Year maximum applies to all benefits paid under this Option and any other Option under the Plan.
2 Out-of-pocket maximum. Charges for the following are not applied to meeting your out-of-pocket maximum and are never paid at 100%:
Deductible Ineligible charges and excluded charges Charges that exceed Allowable Charges Any amounts that exceed any Calendar Year or other limit Proton beam therapy Orthotripsy Durable Medical Equipment (DME) Genetic analysis Prosthetics Electrical Stimulators Other orthotics 3 For maternity, benefits are subject to the same plan provisions as all other medical conditions.
4 Up to a maximum of $1,250 per day for ICU and up to a maximum of $500 per day for all other room and board.
5 In-network benefits after applying Allowable Charges will be provided for charges for treatment for an Illness or Injury which is sudden, life
or limb threatening which requires prompt medical treatment and would result in serious effects on the Covered Person's health if not
immediately treated

6.Tier 1 applies when specialty drug is dispensed by specialty pharmacy. Tier 2 applies when specialty drug is billed by in-network provider.

All other provisions, limitations and exclusions apply. SPECIALTY DRUGS

Source: http://www.osmahealth.com/forms/HDHP_SCHEDULE_SINGLE_2011.pdf