WELLCO INSURANCE PPO MEMBER NAME: Sydney Smith MEMBER NUMBER: G

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CLAIMS/INQUIRIES: 1-877-876-5432 WELLCO INSURANCE PPO MEMBER NAME: Sydney Smith MEMBER NUMBER: G0134257 GROUP: G013-LP0 EFFECTIVE DATE: 01-01-2013 PRESCRIPTION GROUP #: 013000 PCP CO-PAY: $25 SPECIALIST CO-PAY: $50 EMERGENCY CO-PAY: $100 PRESCRIPTION CO-PAY $10 GENERIC $20 NAME BRAND MEMBER SERVICES: 1-888-234-5678 CLAIMS/INQUIRIES: 1-877-876-5432

Category I Codes Category II Codes Category III Codes Evaluation and Management Services (99201-99499) Anesthesia (00100 to 01999) Surgery (10021 to 69990) Radiology, Nuclear Medicine, Diagnostic Ultrasound (70010 to 79999) Pathology and Laboratory (80048 to 89356) Medicine (90281 to 99602) Category II Codes Have an alphanumeric identifier with a letter in the last field (e.g., 0502F). These codes are optional and are mainly for tracking and statistical purposes. Category III Codes Are temporary and used to code emerging technologies. These do not yet have a code assigned in Category I. There are in this “limbo” area until the AMA determines the widespread use and clinical effectiveness of the procedure. Upon updating and review, these codes may be moved to Category I, or eliminated completely from the manual.