AMERICAN SPECIALTY HEALTH PLANS GROUP SUBSCRIBER AGMT 1998

• • ATTACHMENT A AMERICAN SPECIALTY HEATLH PLANS FORMERLYAMERICANCHIROPRACTICNETWORKHEALTHPLAN, INC. SCHEDULE OF BENEFITS CALCULATION OF ANNUAL MAXIMUM BENEFIT LIMITS: Each visit to a Participating Chiropractor, as described below, requires a Copayment by the Member. A maximum number of visits per calendar year will apply to each Member. Conjunctive Therapy is allowed at each office visit, if authorized by ASHP. If Conjunctive Therapy is provided without an adjustment, the conjunctive therapy will count as an office visit towards the annual maximums. If an examination or re-examination is supplied without an adjustment, the examination or re- examination will count as an office visit towards the patient's annual maximum. PROVIDER ELIGIBILITY: ASHP only contracts with duly licensed California Chiropractors, Chiropractic Radiologists, Radiology Groups, Clinical Laboratory Groups, Medical Radiologists, Medical Pathologists and Hospitals. Members must use participating providers. TYPES OF COVERED SERVICES a) An Initial Examination is performed by the Participating Chiropractor to determine the nature of the member's problem, and, if chiropractic services appear warranted, to prepare the Treatment Plan of services to be furnished. Each Member is entitled to one initial examination. A Copayment will be required for such examination. b) Subsequent Office Visits, as set forth in the Treatment Plan, may involve an adjustment, a brief re- examination, and other services, in various combinations. c) Conjunctive Therapy, as set forth in the Treatment Plan, may involve therapies such as ultrasound, hot packs, cold packs, electrical muscle stimulation and other therapies. d) A re-examination may be performed by the Participating Chiropractor to assess the need to continue, extend or change the Treatment Plan under which the Member is being treated. A reevaluation may be performed during a subsequent office visit or separately. If performed separately, a Copayment will be required. e) X-rays and laboratory tests are payable in full when referred by a Participating Chiropractor and authorized by ASHP. Radiological consultations are a covered benefit when authorized by ASHP as medically necessary and provided by a licensed Chiropractic Radiologist, Medical Radiologist, Radiology Group, or Hospital f) Chiropractic Appliances are payable up to a maximum of $50.00 per year when prescribed by a Participating Chiropractor and authorized by ASHP; which includes: elbow supports, back supports (thoracic), cervical collars, cervical pillows, heal lifts, hot or cold packs, support/lumbar braces/supports, lumbar cushions, orthotics, wrist supports, rib belts, home traction units (cervical or lumbar), ankle brace, knee brace, rib supports, and wrist brace or other related services.