Common use of Biofeedback Clause in Contracts

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan Member, there will be no cost to you for anything related to COVID-19 screening, testing, medical treatment, or vaccination, including boosters. You will not pay copays, deductibles or coinsurance for visits related to COVID-19, whether at a clinic, hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: · Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan Membermember, there will be no cost to you for anything related to COVID-19 screening, testing, testing or medical treatment, or vaccination, including boosters. You will not pay copays, deductibles or coinsurance for visits related to COVID-19, whether at a clinic, hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Health Care Services and Observation Services Section. Covered Services are as follows: · • Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · • The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · • The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · • Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · • Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · • Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · • Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan Membermember, there will be no cost to you for anything related to COVID-19 screening, testing, testing or medical treatment, or vaccination, including boosters. You will not pay copaysCopays, deductibles Deductibles or coinsurance Coinsurance for visits related to COVID-19, whether at a clinic, hospital Hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: · • Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · • The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · • The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · • Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · • Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · • Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · • Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education. Diabetes Education (Limited). The following benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education: • Medically Necessary visits upon the diagnosis of diabetes • Visits following a Practitioner/Provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient’s self-management • Visits when re-education or refresher training is prescribed by a healthcare Practitioner/Provider with prescribing authority • Telephonic visits with a Certified Diabetes Educator (CDE) • Medical nutrition therapy related to diabetes management Approved diabetes educators must be part of our In-Network Practitioners/Providers who are registered, certified or licensed Healthcare Professional with recent education in diabetes management. Diabetes supplies and services. The following equipment, supplies, appliances, and services are Covered when prescribed by your Practitioner/Provider and when obtained through the designated network Provider: • Insulin pumps when Medically Necessary, prescribed by an In-network endocrinologist • Specialized monitors/meters for the legally blind • Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes. Refer to the Durable Medical Equipment Benefits Section. • Preferred Prescriptive diabetic oral agents for controlling blood sugar levels – Refer to your Formulary for Preferred agents • Glucagon emergency kits • Preferred Insulin - Refer to your Formulary for Preferred Insulin • Syringes • Injection aids, including those adaptable to meet the needs of the legally blind • Preferred Blood glucose monitors/meters – Refer to your Formulary for Preferred monitors • Preferred Test strips for blood glucose monitors – Refer to your Formulary for Preferred Test strips • Preferred Lancets and lancet devices • Preferred Continuous Glucose Monitoring (CGM) including system, sensor, and transmitter. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Refer to your Formulary for Preferred CGM. • Visual reading urine ketone strips These items require the use of approved brands and must be purchased at an In- network Pharmacy, Preferred vendor or Preferred Durable Medical Equipment (DME) supplier. Please contact our Presbyterian Customer Service Center from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. TTY users may call 711. You may also visit their website at xxx.xxx.xxx for further information. Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services when Medically Necessary and provided under the direction of your Practitioner/Provider. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Examples of Covered procedures include, but are not limited to, the following: • Computerized Axial Tomography (CAT) scans – requires Prior Authorization • Magnetic Resonance Angiogram (MRA) tests, Magnetic Resonance Imaging (MRI) tests – require Prior Authorization • Sleep disorder studies in home or facility • Bone density studies • Clinical laboratory tests • Gastrointestinal lab procedures • Pulmonary function tests • Radiology/X-ray services Diagnostic service includes services like mammography, PAP Smears and colonoscopies that are also considered Preventative and are provided to you at $0 cost share. Some services like exploratory surgery, angiograms, imaging, or follow-up procedures to Preventative services can also be diagnostic, but not Preventative and would apply the appropriate Cost-Share (Copay, Coinsurance) based on the service. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids This benefit has one or more exclusions as specified in the Exclusions Section.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan Member, there will be no cost to you for anything related to COVID-19 screening, testing, medical treatment, or vaccination, including boosters. You will not pay copays, deductibles or coinsurance for visits related to COVID-19, whether at a clinic, hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: · • Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · • The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · • The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · • Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · • Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · • Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · • Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services‌‌ This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education. Diabetes Education (Limited) The following benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education: • Medically Necessary visits upon the diagnosis of diabetes • Visits following a Practitioner/Provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient’s self-management • Visits when re-education or refresher training is prescribed by a healthcare Practitioner/Provider with prescribing authority • Telephonic visits with a Certified Diabetes Educator (CDE) • Medical nutrition therapy related to diabetes management Approved diabetes educators must be part of our In-Network Practitioners/Providers who are registered, certified or licensed Healthcare Professional with recent education in diabetes management. Diabetes supplies and services The following equipment, supplies, appliances, and services are Covered when prescribed by your Practitioner/Provider and when obtained through the designated network Provider: • Preferred insulin pumps - Some services require Prior Authorization. Refer to your Formulary for Preferred insulin pumps. • Specialized monitors/meters for the legally blind. • Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes. Refer to the Durable Medical Equipment Benefits Section. • Preferred Prescriptive diabetic oral agents for controlling blood sugar levels – refer to your Formulary for Preferred agents. • Glucagon emergency kits. • Preferred insulin – refer to your Formulary for Preferred Insulin. • Syringes. • Injection aids, including those adaptable to meet the needs of the legally blind. • Preferred blood glucose monitors/meters – refer to your Formulary for Preferred monitors. • Preferred test strips for blood glucose monitors – refer to your Formulary for Preferred test strips. • Preferred lancets and lancet devices. • Preferred continuous glucose monitoring (CGM) including system, sensor, and transmitter. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Refer to your Formulary for Preferred CGM. • Visual reading urine ketone strips. These items require the use of approved brands and must be purchased at an In- network Pharmacy, Preferred vendor or Preferred Durable Medical Equipment (DME) supplier. Please contact our Presbyterian Customer Service Center from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. TTY users may call 711. You may also visit their website at xxx.xxx.xxx for further information. Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services when Medically Necessary and provided under the direction of your Practitioner/Provider. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Examples of Covered procedures include, but are not limited to, the following: • Computerized Axial Tomography (CAT) scans – requires Prior Authorization • Magnetic Resonance Angiogram (MRA) tests, Magnetic Resonance Imaging (MRI) tests – requires Prior Authorization • Sleep disorder studies in home or facility may require Prior Authorization • Bone density studies • Clinical laboratory tests – may require Prior Authorization • Gastrointestinal lab procedures • Pulmonary function tests • Radiology/X-ray services Diagnostic service includes services like mammography, PAP Smears and colonoscopies that are also considered Preventive and are provided to you at $0 Cost Sharing. Some services like exploratory surgery, angiograms, imaging, or follow-up procedures to Preventive services can also be diagnostic, but not Preventive and would apply the appropriate Cost Sharing (Copay, Coinsurance) based on the service.‌ Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids This benefit has one or more exclusions as specified in the Exclusions Section.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan MemberInsurance Company member, there will be no cost to you for anything related to COVID-19 screening, testing, medical treatment, or vaccination, including boostersvaccinations. You will not pay copaysCopays, deductibles Deductibles or coinsurance Coinsurance for visits related to COVID-19, whether at a clinic, hospital Hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: · • Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · • The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · • The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · • Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · • Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · space.‌ • Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · • Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education. Diabetes Education (Limited) The following benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education: • Medically Necessary visits upon the diagnosis of diabetes • Visits following a Practitioner/Provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient’s self-management • Visits when re-education or refresher training is prescribed by a healthcare Practitioner/Provider with prescribing authority • Telephonic visits with a Certified Diabetes Educator (CDE) • Medical nutrition therapy related to diabetes management Practitioners/Providers who are approved diabetes educators must be a registered, certified or licensed Healthcare Professional with recent education in diabetes management. Diabetes supplies and services‌ The following equipment, supplies, appliances, and services are Covered when prescribed by your Practitioner/Provider and when obtained through the designated network Provider: • Preferred Insulin pumps - Some services require Prior Authorization. Refer to your Formulary for Preferred Insulin pumps • Specialized monitors/meters for the legally blind • Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes. Refer to the Durable Medical Equipment Benefits Section. • Preferred Prescriptive diabetic oral agents for controlling blood sugar levels – Refer to your Formulary for Preferred agents at xxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf • Glucagon emergency kits • Preferred Insulin - Refer to your Formulary for Preferred Insulin • Syringes • Injection aids, including those adaptable to meet the needs of the legally blind • Preferred Blood glucose monitors/meters – Refer to your Formulary for Preferred monitors • Preferred Test strips for blood glucose monitors – Refer to your Formulary for Preferred Test strips • Preferred Lancets and lancet devices • Preferred Continuous Glucose Monitoring (CGM) including system, sensor, and transmitter. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Refer to your Formulary for preferred CGM • Visual reading urine ketone strips Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) Coverage is provided for Diagnostic Services when provided under the direction of your Practitioner/Provider. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Examples of Covered procedures include, but are not limited to, the following: • Computerized Axial Tomography (CAT) scans – requires Prior Authorization • Magnetic Resonance Angiogram (MRA) tests, Magnetic Resonance Imaging (MRI) tests – require Prior Authorization‌‌ • Sleep disorder studies in home or facility • Bone density studies • Clinical laboratory tests • Gastrointestinal lab procedures • Pulmonary function tests • Radiology/X-ray services Diagnostic service includes services like mammography, PAP Smears and colonoscopies that are also considered Preventative and are provided to you at $0 Cost Sharing. Some services like exploratory surgery, angiograms, imaging, or follow-up procedures to Preventative services can also be diagnostic, but not Preventative and would apply the appropriate Cost Sharing (Copay, Coinsurance) based on the service. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids This benefit has one or more exclusions as specified in the Exclusions Section.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan MemberInsurance Company member, there will be no cost to you for anything related to COVID-19 screening, testing, medical treatment, or vaccination, including boosters. You will not pay copaysCopays, deductibles Deductibles or coinsurance Coinsurance for visits related to COVID-19, whether at a clinic, hospital Hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: · • Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · • The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · • The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · • Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · • Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · • Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · • Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services‌‌ This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education. Diabetes Education (Limited) The following benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education: • Medically Necessary visits upon the diagnosis of diabetes • Visits following a Practitioner/Provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient’s self-management • Visits when re-education or refresher training is prescribed by a healthcare Practitioner/Provider with prescribing authority • Telephonic visits with a Certified Diabetes Educator (CDE) • Medical nutrition therapy related to diabetes management Practitioners/Providers who are approved diabetes educators must be a registered, certified or licensed Healthcare Professional with recent education in diabetes management. Diabetes supplies and services The following equipment, supplies, appliances, and services are Covered when prescribed by your Practitioner/Provider and when obtained through the designated network Provider: • Preferred Insulin pumps – Some services require Prior Authorization. Refer to your Formulary for Preferred Insulin pumps • Specialized monitors/meters for the legally blind • Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes. Refer to the Durable Medical Equipment Benefits Section. • Preferred Prescriptive diabetic oral agents for controlling blood sugar levels – Refer to your Formulary for Preferred agents at xxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf • Glucagon emergency kits • Preferred Insulin - Refer to your Formulary for Preferred Insulin • Syringes • Injection aids, including those adaptable to meet the needs of the legally blind • Preferred Blood glucose monitors/meters – Refer to your Formulary for Preferred monitors • Preferred Test strips for blood glucose monitors – Refer to your Formulary for Preferred Test strips • Preferred Lancets and lancet devices • Preferred Continuous Glucose Monitoring (CGM) including system, sensor, and transmitter. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Refer to your Formulary for Preferred CGM. • Visual reading urine ketone strips Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) Coverage is provided for Diagnostic Services when provided under the direction of your Practitioner/Provider. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Examples of Covered procedures include, but are not limited to, the following: • Computerized Axial Tomography (CAT) scans – requires Prior Authorization • Magnetic Resonance Angiogram (MRA) tests, Magnetic Resonance Imaging (MRI) tests – require Prior Authorization • Sleep disorder studies in home or facility • Bone density studies • Clinical laboratory tests • Gastrointestinal lab procedures • Pulmonary function tests • Radiology/X-ray services Diagnostic service includes services like mammography, PAP Smears and colonoscopies that are also considered Preventative and are provided to you at $0 Cost Sharing. Some services like exploratory surgery, angiograms, imaging, or follow-up procedures to Preventative services can also be diagnostic, but not Preventative and would apply the appropriate Cost Sharing (Copay, Coinsurance) based on the service.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan Membermember, there will be no cost to you for anything related to COVID-19 screening, testing, medical treatment, or vaccination, including boosters. You will not pay copaysCopays, deductibles Deductibles or coinsurance Coinsurance for visits related to COVID-19, whether at a clinic, hospital Hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: · • Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · • The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · • The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · • Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · • Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · • Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · • Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan Member, there will be no cost to you for anything related to COVID-19 screening, testing, medical treatment, or vaccination, including boosters. You will not pay copays, deductibles or coinsurance for visits related to COVID-19, whether at a clinic, hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (traumaTrauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: ·  Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. ·  The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. ·  The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. ·  Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization requestmay be required. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. ·  Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. ·  Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. ·  Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education. Coverage for individuals with diabetes may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate, as long as the annual deductibles or coinsurance for benefits are no greater than the annual deductibles or coinsurance established for similar benefits within a given policy. Diabetes Education and Self-Management Training The following benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education:  Medically Necessary diabetes education and self-management training visits upon the diagnosis of diabetes  Visits following a Practitioner/Provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient’s self-management  Visits when re-education or refresher training is prescribed by a healthcare Practitioner/Provider with prescribing authority  Telephonic visits with a Certified Diabetes Educator (CDE)  Medical nutrition therapy related to diabetes management Approved diabetes educators must be part of our In-Network Practitioners/Providers who are registered, certified or licensed Healthcare Professional with recent education in diabetes management. Diabetes supplies, equipment, appliances, and services The following equipment, supplies, appliances, and services are Covered when prescribed by your Practitioner/Provider and when obtained through the designated network Provider  Insulin pumps.  Insulin Management Systems (Omnipod).  Formulary Continuous Glucose Monitoring (CGM) including system, sensor, and transmitter.  Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes – refer to the Durable Medical Equipment Benefits Section.  Formulary oral diabetic agents for controlling blood sugar levels.  Glucagon emergency kits.  Formulary Insulin Syringes.  Injection aids, including those for individuals with disabilities, including those adaptable to meet the needs of the legally blind.  Formulary Blood Glucose Monitors/Meters including specialized monitors/meters for the legally blind.  Formulary Test strips for blood glucose monitors.  Formulary Lancets and lancet devices.  Visual reading urine ketone strips.  Alcohol swabs. Some services may require Prior Authorization. Please contact our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 1-800-356- 2219. TTY users may call 711. You may also visit Pharmacy Resources - Drug Formularies | Presbyterian Health Plan, Inc. (xxx.xxx). Presbyterian will provide reimbursement within 30 days when a member paid out-of-pocket due to untimely receipt of ordered equipment, appliances, supplies and insulin or other prescription drugs. Presbyterian will pay interest at the rate of 18 percent per year on the amount of reimbursement due to a covered person if not paid within 30 days. Presbyterian does not require more than one Prior Authorization (PA) per policy year, per prescribed diabetes drug or item. These items require the use of approved brands and must be purchased at an In- network Pharmacy, Preferred vendor or Preferred Durable Medical Equipment (DME) supplier. Please contact our Presbyterian Customer Service Center from7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. TTY users may call 711. You may also visit their website at xxx.xxx.xxx for further information. Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services when Medically Necessary and provided under the direction of your Practitioner/Provider. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Examples of Covered procedures include, but are not limited to, the following:  Artery calcification testing (plan year 2022 and after)  Biomarker Testing  Computerized Axial Tomography (CAT) scans – requires Prior Authorization  Magnetic Resonance Angiogram (MRA) tests, Magnetic Resonance Imaging (MRI) tests – requires Prior Authorization  Sleep disorder studies in home or facility. In facility sleep studies require Prior Authorization  Bone density studies  Clinical laboratory tests - may require Prior Authorization  Gastrointestinal lab procedures  Pulmonary function tests  Radiology/X-ray services  Diagnostic Breast Exams  Supplemental Breast Exam Diagnostic service includes services like mammography, PAP Smears and colonoscopies that are also considered Preventive and are provided to you at $0 Cost Sharing. Some services like exploratory surgery, angiograms, imaging, or follow-up procedures to Preventive services can also be diagnostic, but not Preventive and would apply the appropriate Cost Sharing (Copay, Coinsurance) based on the service. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids This benefit has one or more exclusions as specified in the Exclusions Section.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan MemberInsurance Company member, there will be no cost to you for anything related to COVID-19 screening, testing, medical treatment, or vaccination, including boosters. You will not pay copaysCopays, deductibles Deductibles or coinsurance Coinsurance for visits related to COVID-19, whether at a clinic, hospital Hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: · • Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · • The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · • The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · • Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · • Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · • Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · • Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services‌‌ This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education. Diabetes Education (Limited) The following benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education: • Medically Necessary visits upon the diagnosis of diabetes • Visits following a Practitioner/Provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient’s self-management • Visits when re-education or refresher training is prescribed by a healthcare Practitioner/Provider with prescribing authority • Telephonic visits with a Certified Diabetes Educator (CDE) • Medical nutrition therapy related to diabetes management Practitioners/Providers who are approved diabetes educators must be a registered, certified or licensed Healthcare Professional with recent education in diabetes management. Diabetes supplies and services The following equipment, supplies, appliances, and services are Covered when prescribed by your Practitioner/Provider and when obtained through the designated network Provider: • Preferred Insulin pumps – Some services require Prior Authorization. Refer to your Formulary for preferred Insulin pumps • Specialized monitors/meters for the legally blind • Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes. Refer to the Durable Medical Equipment Benefits Section. • Preferred Prescriptive diabetic oral agents for controlling blood sugar levels – Refer to your Formulary for Preferred agents at xxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. • Glucagon emergency kits • Preferred Insulin - Refer to your Formulary for Preferred Insulin • Syringes • Injection aids, including those adaptable to meet the needs of the legally blind • Preferred Blood glucose monitors/meters – Refer to your Formulary for Preferred monitors • Preferred Test strips for blood glucose monitors – Refer to your Formulary for Preferred Test strips • Preferred Lancets and lancet devices • Preferred Continuous Glucose Monitoring (CGM) including system, sensor, and transmitter. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Refer to your Formulary for Preferred CGM. • Visual reading urine ketone strips Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) Coverage is provided for Diagnostic Services when provided under the direction of your Practitioner/Provider. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Examples of Covered procedures include, but are not limited to, the following: • Computerized Axial Tomography (CAT) scans – requires Prior Authorization • Magnetic Resonance Angiogram (MRA) tests, Magnetic Resonance Imaging (MRI) tests – require Prior Authorization • Sleep disorder studies in home or facility • Bone density studies • Clinical laboratory tests • Gastrointestinal lab procedures • Pulmonary function tests • Radiology/X-ray services Diagnostic service includes services like mammography, PAP Smears and colonoscopies that are also considered Preventative and are provided to you at $0 Cost Sharing. Some services like exploratory surgery, angiograms, imaging, or follow-up procedures to Preventative services can also be diagnostic, but not Preventative and would apply the appropriate Cost Sharing (Copay, Coinsurance) based on the service.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan MemberInsurance Company member, there will be no cost to you for anything related to COVID-19 screening, testing, testing or medical treatment, or vaccination, including boosters. You will not pay copaysCopays, deductibles Deductibles or coinsurance Doinsurance for visits related to COVID-19, whether at a clinic, hospital Hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Health Care Services and Observation Services Section. Covered Services are as follows: · • Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · • The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · • The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · • Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · • Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · • Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · • Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services‌‌ This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education. Diabetes Education (Limited) The following benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education: • Medically Necessary visits upon the diagnosis of diabetes • Visits following a Practitioner/Provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient’s self-management • Visits when re-education or refresher training is prescribed by a healthcare Practitioner/Provider with prescribing authority • Telephonic visits with a Certified Diabetes Educator (CDE) • Medical nutrition therapy related to diabetes management Practitioners/Providers who are approved diabetes educators must be a registered, certified or licensed Health Care Professional with recent education in diabetes management. Diabetes supplies and services The following equipment, supplies, appliances, and services are Covered when prescribed by your Practitioner/Provider and when obtained through the designated network Provider: • Insulin pumps when Medically Necessary, prescribed by an In-network endocrinologist • Specialized monitors/meters for the legally blind • Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes. Refer to the Durable Medical Equipment Benefits Section. • Preferred Prescriptive diabetic oral agents for controlling blood sugar levels – Refer to your Formulary for Preferred agents at xxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf • Glucagon emergency kits • Preferred Insulin - Refer to your Formulary for Preferred Insulin • Syringes • Injection aids, including those adaptable to meet the needs of the legally blind • Preferred Blood glucose monitors/meters – Refer to your Formulary for Preferred monitors • Preferred Test strips for blood glucose monitors – Refer to your Formulary for Preferred Test strips • Preferred Lancets and lancet devices • Preferred Continuous Glucose Monitoring (CGM) including system, sensor, and transmitter. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Refer to your Formulary for Preferred CGM. • Visual reading urine ketone strips Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) Coverage is provided for Diagnostic Services when provided under the direction of your Practitioner/Provider. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Examples of Covered procedures include, but are not limited to, the following: • Computerized Axial Tomography (CAT) scans – requires Prior Authorization • Magnetic Resonance Angiogram (MRA) tests, Magnetic Resonance Imaging (MRI) tests – require Prior Authorization • Sleep disorder studies in home or facility • Bone density studies • Clinical laboratory tests • Gastrointestinal lab procedures • Pulmonary function tests • Radiology/X-ray services Diagnostic service includes services like mammography, PAP Smears and colonoscopies that are also considered Preventative and are provided to you at $0 cost share. Some services like exploratory surgery, angiograms, imaging, or follow-up procedures to Preventative services can also be diagnostic, but not Preventative and would apply the appropriate Cost-Share (Copay, Coinsurance) based on the service. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids‌‌‌ This benefit has one or more exclusions as specified in the Exclusions Section.

Biofeedback. Biofeedback is only Covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence. COVID-19 As a Presbyterian Health Plan Membermember, there will be no cost to you for anything related to COVID-19 screening, testing, medical treatment, or vaccination, including boosters. You will not pay copaysCopays, deductibles Deductibles or coinsurance Coinsurance for visits related to COVID-19, whether at a clinic, hospital Hospital or using remote care. If you are on a high deductible plan (HDHP), these services will also be provided to you at no cost. Dental Services (Limited) This benefit has one or more exclusions as specified in the Exclusions Section. Dental benefits will be provided in connection with the following conditions when deemed Medically Necessary except in an emergency situation as described in the Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services and Observation Services Section. Covered Services are as follows: · Accidental Injury to sound natural teeth, jawbones or surrounding tissue. Dental injury caused by chewing, biting, or Malocclusion is not considered an Accidental Injury and will not be Covered. · The correction of non-dental physiological conditions such as, but not limited to, cleft palate repair that has resulted in a severe functional impairment. · The treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. · Hospitalization, day surgery, Outpatient and/or anesthesia for non- Covered dental services, are Covered, if provided in a Hospital or ambulatory surgical center for dental surgery, with our approval of a Prior Authorization request. Plan benefits for these services include coverage: o For Members who exhibit physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results. o For Members for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy. o For Covered Dependent children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity. o For Members with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. o For other procedures for which Hospitalization or general anesthesia in a Hospital or ambulatory surgical center is Medically Necessary. · Oral surgery that is Medically Necessary to treat infections or abscess of the teeth that involved the fascia or have spread beyond the dental space. · Removal of infected teeth in preparation for an Organ transplant, joint replacement surgery or radiation therapy of the head and neck. · Temporo/Craniomandibular Joint Disorders (TMJ/CMJ) o The surgical and non-surgical treatment of Temporo/Craniomandibular Joint disorders (TMJ/CMJ) such as arthroscopy, physical therapy, or the use of Orthotic Devices (TMJ splints) are subject to the same conditions, limitations, and may require Prior Authorization as they apply to treatment of any other joint in the body. Diabetes Services This benefit has one or more exclusions as specified in the Exclusions Section. Covered Benefits are provided if you have insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education. Diabetes Education (Limited) The following benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education: · Medically Necessary visits upon the diagnosis of diabetes · Visits following a Practitioner/Provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient’s self-management · Visits when re-education or refresher training is prescribed by a healthcare Practitioner/Provider with prescribing authority · Telephonic visits with a Certified Diabetes Educator (CDE) · Medical nutrition therapy related to diabetes management Approved diabetes educators must be part of our In-Network Practitioners/Providers who are registered, certified or licensed Healthcare Professional with recent education in diabetes management. Diabetes supplies and services The following equipment, supplies, appliances, and services are Covered when prescribed by your Practitioner/Provider and when obtained through the designated network Provider: · Preferred Insulin pumps - Some services require Prior Authorization. Refer to your Formulary for Preferred Insulin pumps · Specialized monitors/meters for the legally blind · Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes. Refer to the Durable Medical Equipment Benefits Section. · Preferred Prescriptive diabetic oral agents for controlling blood sugar levels – Refer to your Formulary for Preferred agents · Glucagon emergency kits · Preferred Insulin - Refer to your Formulary for Preferred Insulin · Syringes · Injection aids, including those adaptable to meet the needs of the legally blind · Preferred Blood glucose monitors/meters – Refer to your Formulary for Preferred monitors · Preferred Test strips for blood glucose monitors – Refer to your Formulary for Preferred Test strips · Preferred Lancets and lancet devices · Preferred Continuous Glucose Monitoring (CGM) including system, sensor, and transmitter. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Refer to your Formulary for Preferred CGM. · Visual reading urine ketone strips These items require the use of approved brands and must be purchased at an In- network Pharmacy, Preferred vendor or Preferred Durable Medical Equipment (DME) supplier. Please contact our Presbyterian Customer Service Center from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. TTY users may call 711. You may also visit their website at xxx.xxx.xxx for further information. Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services when Medically Necessary and provided under the direction of your Practitioner/Provider. Some services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. Examples of Covered procedures include, but are not limited to, the following: · Computerized Axial Tomography (CAT) scans – requires Prior Authorization · Magnetic Resonance Angiogram (MRA) tests, Magnetic Resonance Imaging (MRI) tests – requires Prior Authorization · Sleep disorder studies in home or facility may require Prior Authorization · Bone density studies · Clinical laboratory tests - may require Prior Authorization · Gastrointestinal lab procedures · Pulmonary function tests · Radiology/X-ray services Diagnostic service includes services like mammography, PAP Smears and colonoscopies that are also considered Preventive and are provided to you at $0 Cost Sharing. Some services like exploratory surgery, angiograms, imaging, or follow-up procedures to Preventive services can also be diagnostic, but not Preventive and would apply the appropriate Cost Sharing (Copay, Coinsurance) based on the service. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids This benefit has one or more exclusions as specified in the Exclusions Section.