Fill and Sign the Missouri Llc Operating Agreement Form

Compare Your PPO Medical Options (Aetna Choice POS II, CareFirst Annual out-ofpocket maximum (includes deductibles; excludes copayments) Lifetime benefit limit Emergency room care/ Urgent care facility In-network $400 per person; $800 family limit $1,500 per person; $3,000 family limit None You pay $50 (waived if admitted)/$25 copayment per visit Out-of-network (1) $750 per person; $1,500 family limit $3,000 per person; $6,000 family limit $1 million per person You pay $50 (waived if admitted)/$25 copayment per visit In-network None $500 per person; $1,000 family limit None You pay $50 (waived if admitted)/$25 copayment per visit Out-of-network (1) $400 per person; $800 family limit $2,000 per person; $5,000 family limit $1 million per person You pay $50 (waived if admitted)/$25 copayment per visit (Same as Core Plan or Coinsurance Option) (5) (Same as Core Plan or Coinsurance Option) (5) None $1,000 per person; $3,000 family limit $1 million per person You pay $50 (waived if admitted)/$25 copayment per visit None $1,000 per person; $3,000 family limit $1 million per person Plan pays 80% Feature Annual deductible (excludes copayments) PPO/POS/OAP Plan Core Plan Coinsurance Option International Out-of-Area Office Visit Copayment Options 1. $10 in-network PCP; $20 in-network specialist 2. $20 out-of-network PCP; $40 in-network specialist These charts serve as a summary of benefits. In cases of discrepancy, plan documents prevail. 12 None You pay $50 (waived if admitted)/$25 copayment per visit BCBS PPO, CIGNA Open Access Plus) Inpatient hospital services Surgery (inpatient and outpatient) PCP or generalist office Specialist office visit visit Well-care visits (2) n Routine gynecological exams, physical exams, and well-child care n Immunizations n Flu shots Preventive screenings (2) n Pap smear n Mammogram n Prostate cancer screening n Flexible sigmoidoscopy n Colonoscopy Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 100% Plan pays 100% Plan pays 60% after deductible Plan pays 60% after deductible Plan pays 60% after deductible Plan pays 60% after deductible Plan pays 60% after deductible Plan pays 60% after deductible You pay $200 annual Plan pays 90% copayment; then the plan pays 90% Plan pays 90% Plan pays 90% Plan pays 100% Plan pays 100% You pay $400 annual copayment; then the plan pays 70% after deductible Plan pays 70% after deductible Plan pays 70% after deductible Plan pays 70% after deductible Plan pays 70% after deductible You pay $10 copayment per visit; then the plan pays 100% (3) You pay $20 copayment per visit; then the plan pays 100% (3) Plan pays 100% Plan pays 100% Plan pays 70% after deductible (Same as Core Plan or Coinsurance Option) (5) (Same as Core Plan or Coinsurance Option) (5) You pay $200 annual deductible; then the plan pays 100% Plan pays 80% Plan pays 80% Plan pays 80% Plan pays 100% Plan pays 100% You pay $200 annual deductible; then the plan pays 100% Plan pays 80% Plan pays 80% Plan pays 80% Plan pays 100% (80% for flu shots) Plan pays 100% You pay $20 copayment You pay $40 copayment per visit; then the plan pays per visit; then the plan 100% (3) pays 100% (3) (1) Medical expenses are balance billed up to the reasonable and customary (R&C) amount or allowed benefit amount, as determined by the Administrator. You are responsible for any amounts above the R&C amount or allowed benefit amount. (2) Guidelines apply in terms of frequency of exams, age requirements, etc. (3) If you go out-of-network, the plan pays according to out-of-network coverage in the Core PPO plan or the Coinsurance Option, depending on which you elect for 2009. 13 X-rays and lab tests (2,4) Physical, occupational, and speech therapy (6) Chiropractic care ($1,500 combined annual maximum) Infertility services (combined maximum lifetime benefit of $40,000) Mental Health/ Substance Abuse Inpatient services Mental Health/ Substance Abuse Outpatient services Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 60% after deductible Plan pays 60% after deductible Plan pays 60% after deductible Plan pays 50% after deductible Plan pays 60% after deductible Plan pays 60% after deductible Plan pays 90% Plan pays 90% Plan pays 90% Plan pays 90% You pay $200 annual Plan pays 90% after copayment, then the plan deductible pays 90% Plan pays 70% after deductible Plan pays 70% after deductible Plan pays 70% after deductible Plan pays 50% after deductible You pay $400 annual copayment, then the plan pays 70% after deductible You pay $20 copayment per visit; then the plan pays 100% (3) You pay $20 copayment per visit; then the plan pays 100% (3) You pay $20 copayment for office visits, including testing and counseling (3) (Same as Core Plan or Coinsurance ­­Option) (5) Play pays 70% after deductible You pay $20 copayment per visit (Other services covered same as Core Plan or Coinsurance Plan) (5) (Same as Core Plan or Coinsurance Plan) (5) You pay $40 copayment per visit; then the plan pays 100% (3) You pay $40 copayment per visit; then the plan pays 100% (3) You pay $40 copayment for office visits, including testing and counseling (3) Plan pays 80% Plan pays 80% Plan pays 80% Plan pays 50% You pay $200 annual deductible, then plan pays 100% Plan pays 80% Plan pays 80% Plan pays 80% (60 visits per year) Plan pays 80%, not subject to combined annual maximum (60 visits per year) Plan pays 80%, not subject to maximum Plan pays 80% Plan pays 80% (up to 60 visits per year) You pay $40 copayment per visit (Other services covered same as Core Plan or Coinsurance Plan) (5) (4) X-rays and lab tests associated with well-care visits and preventive screenings are covered at 100%. (5) Out-of-network copayment options revert back to the core or coinsurance options and are subject to deductibles and appropriate coinsurance payments. (6) Certain diagnoses for speech therapy are not covered. 14