R2001-191 AUTHORIZING APPLICATIONS

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SCHEDULE OF BEiVEFITS Verification of Eligibility(217)423-7788 or(800)798-2422 Call[his number to verify eligibility for Plan benefits before the charge is incurred. MEDICAL BENEFITS All benefits described in this Schedule are subject to the exclusions and limitations described more fully herein including,but not limited to, the Plan Administrator's deternunation that: care and treatment is Medically Necessary; that charges are Usual and Reasonable;that services, supplies and care are not Experimental and/or Investigational. The meanings of these capitalized terms are in the Defined Terms section of this document. Note: The following services must be precert�ed or reimbursement from the Plan may be reduced. The attending Physician does not have to obtain precert�cation from the Plan for prescribing a maternity length of stay that is 48 hours or less for a vaginal delivery or 96 hours or less for a cesarean delivery. Hospitalizations Substance Abuse/Mental Disorder treatments-Inpatient Please see the Cost Management section in this booklet for details. I� The Plan is a plan which contains a Network Provider Organization. �' PPO name: Consociate Care Address: 111 East Decatur Street Decatur,Illinois 62525 Telephone: (217)423-7788 Fax: (217)423-4575 This Plan has entered into an agreement with certain Hospitals, Physicians and other health care providers, which are called Network Providers. Because these Network Providers have agreed to charge reduced fees to persons covered under the Plan,the Plan can afford to reimburse a higher percentage of their fees. Therefore, when a Covered Person uses a Network Provider,that Covered Person will receive a higher payment from the Plan than when a Non-network Provider is used.It is the Covered Person's choice as to which Provider to use. Under the following circumstances,the higher in-Network payment will be made for certain non-Network services: If a Covered Person has no choice of Network Providers in the specialty that the Covered Person is seeking within the PPO service area. If a Covered Person is out of the PPO service area and has a Medical Emergency requiring immediate care. If a Covered Person receives Physician or anesthesia services by a non-Network Provider at an in-Network facility. Additional information about this option, as well as a list of Network Providers, will be given to Plan Participants, at no cost,and updated as needed. Deductibles payable by Plan Participants Deductibles are dollar amounts that the Covered Person must pay before the Plan pays. A deductible is an amount of money that is paid once a Calendar Year per Covered Person.Typically, there is one deductible amount per Plan and it must be paid before any money is paid by the Plan for any covered services.Each 11