Common use of COVERAGE GUIDELINES Clause in Contracts

COVERAGE GUIDELINES. 50% Cov for OP BHCD for RI or Othr Plans Non-Ntwk PPO Prov; 80% Cov all Svc Othr RI or Othr Plans Non-Ntwk PPO Prov up to an OOP Mx $3000 1/3 Per Fam Calyr Aggr BT Hosp & Surg-Med LOB Excl Pedi/IVF/BH/CD; Cov Infertility Treatment Unlimited Days of Care (includes medical/surgical and Inpatient Mental Health Care) Semi-Private Room Emergency Room Care (no authorization required) $100 Emergency Room Care Co-payment (waived if admitted) 12 Chiropractic Visits per calendar year Durable Medical Equipment (80% coverage; no dollar maximum) Diagnostic Tests, Lab and X-Ray Coverage Including Mammograms and Pap Tests Office Visit Coverage Inpatient/Outpatient Surgery, Anesthesia Coverage Maternity Care $25 Office Visit Co-payment per Individual Session for Outpatient Behavioral Health/Chemical Dependency; $25 Office Visit Co-payment Per Group Session for Outpatient Behavioral Health/Chemical Dependency $25 Office Visit Co-payment (excluding chiropractic visits) $25 Office Visit Co-payment for specialists, including but not limited to, Allergy, Dermatology, Obstetrics/Gynecology, and Chiropractic visits. $50 Office Visit for Urgent Care Injectable Prescription Drugs Covered 80% Cov to MM Like Benefits when Packaged w/Preferred Rx (Opt 2) Clinic, Home Inf, HomeCare, Prosth, DME, PDN, Card Rehab, Amb, Prof Ther, Inj, Oxy, Supplies; $7 Gen/$25 Brand Per Month Supply for Pharmacy Submitted Injectables PREVENTIVE CARE: Mammograms Pap Tests PSA Tests Well Baby Care - $15. Co-payment Per Visit, then 100% Coverage up to Allowance $5 (generic drugs), $10 (preferred brand name), and $30 (non-preferred brand names have generic or brand name alternatives): 30-day supply Student Coverage to Age 26 No Lifetime Maximum 80% Coverage for Outpatient Labs and X-Rays from a Hospital Non-Network Provider Organ Transplant Coverage: 100% coverage for eligible costs associated with kidney, cornea, allogenic bone marrow, heart, lung, liver, pancreas, or small intestine transplants Radiation Therapy Services Paid in Full $200 Deductible Per Person (3 Per Family Maximum) per calendar year for Services Rendered by Non-Network Providers or other plans Non-Network PPO Providers Authorization is obtained from providers who participate directly with the healthcare carrier; members responsible for obtaining pre-authorization when using the healthcare carrier’s PPO providers who do not participate directly with the healthcare carrier or from non-network providers. $25 co-payment – one routine exam per calendar year at network providers (medically necessary exams as needed); reimbursed at the health care carrier’s allowance minus a $25 co-payment at non-participating optometrists/ophthalmologists; 80% after deductible for non-participating routine exams only Detox: up to 5 admissions or 30 days in any calendar year, whichever comes first. Rehab: hospital network or community residential care services for chemical dependency treatment facility covered up to 30 days in any calendar year. Outpatient Mental Health: up to 30 visits per member, per calendar year (medication visits are unlimited) Outpatient Chemical Dependency: limited to 30 hours per member, per calendar year for facility-based or office-based counseling or in your home

COVERAGE GUIDELINES. 50% Cov for OP BHCD for RI or Othr Plans Non-Ntwk PPO Prov; 80% Cov all Svc Othr RI or Othr Plans Non-Ntwk PPO Prov up to an OOP Mx $3000 1/3 I/3 Per Fam Calyr Aggr BT Hosp & Surg-Med LOB Excl Pedi/IVF/BH/CD; Cov Infertility Treatment Unlimited Days of Care (includes medical/surgical and Inpatient Mental Health Care) Semi-Private Room Emergency Room Care (no authorization required) $100 Emergency Room Care Co-payment (waived if admitted) 12 Chiropractic Visits per calendar year Durable Medical Equipment (80% coverage; no dollar maximum) Diagnostic Tests, Lab and X-Ray Coverage Including Mammograms and Pap Tests Office Visit Coverage Inpatient/Outpatient Surgery, Anesthesia Coverage Maternity Care $25 15 Office Visit Co-payment per Per Individual Session for Outpatient Behavioral Health/Chemical Dependency; $25 15 Office Visit Co-payment Per Group Session for Outpatient Behavioral Health/Chemical Dependency $25 15 Office Visit Co-payment (excluding including chiropractic visits) $25 15 Office Visit Co-payment for specialists, including but not limited to, Allergy, Dermatology, Obstetrics/Gynecology, Allergy and Chiropractic visits. Dermatology $50 Office Visit for 15 Urgent Care Injectable Prescription Drugs Covered visit 80% Cov to MM Like Benefits when Packaged w/Preferred Rx Opt 2 (Opt 2) Clinic, Home Inf, HomeCareHome Care, Prosth, DME, PDN, Card Rehab, Amb, Prof Ther, Inj, Oxy, Supplies; $7 Gen/$25 Brand Per Month Supply for Pharmacy Submitted Injectables PREVENTIVE CARE: Mammograms Pap Tests PSA Tests Well Baby Care - $15. Co-payment Per Visit, then 100% Coverage up to Allowance $5 (generic drugs), $10 (preferred brand name), and $30 (non-preferred brand names have generic or brand name alternatives): 30-day supply Student Coverage to Age 26 No Lifetime Maximum 80% Coverage for Outpatient Labs and X-Rays from a Hospital Non-Network Provider Organ Transplant Coverage: 100% coverage for eligible costs associated with kidney, cornea, allogenic bone marrow, heart, lung, liver, pancreas, or small intestine transplants Radiation Therapy Services Paid in Full $200 Deductible Per Person (3 Per Family Maximum) per calendar year for Services Rendered by Non-Network Providers or other plans Non-Network PPO Providers Authorization is obtained from providers who participate directly with the healthcare carrier; members responsible for obtaining pre-authorization when using the healthcare carrier’s PPO providers who do not participate directly with the healthcare carrier or from non-network providers. $25 co-payment – one routine exam per calendar year at network providers (medically necessary exams as needed); reimbursed at the health care carrier’s allowance minus a $25 co-payment at non-participating optometrists/ophthalmologists; 80% after deductible for non-participating routine exams only Detox: up to 5 admissions or 30 days in any calendar year, whichever comes first. Rehab: hospital network or community residential care services for chemical dependency treatment facility covered up to 30 days in any calendar year. Outpatient Mental Health: up to 30 visits per member, per calendar year (medication visits are unlimited) Outpatient Chemical Dependency: limited to 30 hours per member, per calendar year for facility-based or office-based counseling or in your home;