Common use of Dental Services - Accidental Injury (Emergency Clause in Contracts

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% $100 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% $25 - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$50 20% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered 20% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$30 20% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered 20% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $150 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible Not Covered teet.h $40 40%- Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility* 0% - After deductible Not 20%- Afterdeductible 40%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 20%- Afterdeductible 40%- Afterdeductible Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits benefitlimits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 2020%- Afterdeductible 40% - After deductible Not Covered Outpatient medical supplies* - Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 2020%- Afterdeductible 40% - After deductible Not Covered Outpatient diabetic Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 2020%- Afterdeductible 40% - After deductible Not Covered Outpatient prosthesis* - Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 2020%- Afterdeductible 40% - After deductible Not Covered Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2020%- Afterdeductible 40% - After deductible Not Covered Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Education - Asthma Asthma management $40 40% - Afterdeductible Emergency Room Services Hospitalemergencyroom $150 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 40% - Afterdeductible Hearing diagnostic testing 0% 40% - Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for a member under 19; thbeenefit limis $700 per hearing aid for a member 19 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services whbeinlled by a home health care agency. 20%- Afterdeductible 40%- Afterdeductible Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 20%- Afterdeductible 40%- Afterdeductible Human Leukocyte AntigenTesting Human leukocyte antigen testing 20%- Afterdeductible 40%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) -ivnitDro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in a P H liPfetimEe. H U ¶ V 20%- Afterdeductible 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefitlimits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Infusion Therapy- Administration Services Outpatient- hospital 20%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 20%- Afterdeductible 40%- Afterdeductible Inpatient Services General hospitaol r specialty hospitaslervices*- unlimited days 20%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility service*s- limited to 45 days peprlan year. 20%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits 20%- Afterdeductible 40%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for details. 0% 40%- Afterdeductible Surgery services- includes mastectomy and reconstructi surgery. See Mastectomy Services in Section 3 for deta 0% 40%- Afterdeductible Mastectom-yrelated treatmen-t includes prostheses and treatment for physical complications. 0% Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible $30 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network providercare coordinated by Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Flex Plan (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay your primary care physician and permitted self-referrals. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$50 20% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Covered Benefits 20% - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered 20% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 20% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network providercare coordinated by your primary care physician and permitted self-referrals. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network providercare coordinated by your primary care physician and permitted self-referrals.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible Not Covered Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $200 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible Not Covered teet.h $50 20%- Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility* 0% - After deductible Not 0%- Afterdeductible 20%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0%- Afterdeductible 20%- Afterdeductible Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Education - Asthma Asthma management 0% 20%- Afterdeductible Emergency Room Services Hospitalemergencyroom $200 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $50 20%- Afterdeductible Hearing diagnostic testing 0% 20%- Afterdeductible Hearing aids- The benefit limit is $2,000 per hearing aid for a member under 21, thbeenefit limit is $700 per hearing aid for a member 21 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services when billed by a home hea care agency. 0%- Afterdeductible 20%- Afterdeductible Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) -ivnitDro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in a P H liPfetimEe. H U ¶ V 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient Services General hospitaol r specialty hospitaslervices*- unlimited days 0%- Afterdeductible 20%- Afterdeductible Rehabilitationfacility service*s- limited to 45 days peprlan year. 0%- Afterdeductible 20%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 20%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for details. 0% 20%- Afterdeductible Surgery services- includes mastectomy and reconstructi surgery. SeeMastectomy Services in Section 3 for detai 0% 20%- Afterdeductible Mastectom-yrelated treatmen-t includes prostheses and treatment for physical complications. 0% Coverage varies based on type of service. Office Visits- (Other than PreventiveCare Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injection-sapplies to injection only, including administration. 0% 20%- Afterdeductible Diabetic office visits Podiatristservices- first routine visit inpalan year $0 20%- Afterdeductible Vision care service-sfirst routine eye exam inpalan yearthat includes a retinal eye exam. $0 20%- Afterdeductible Hospitalbased clinic visits $50 20%- Afterdeductible PCP visits- including behavioral hea.ltVhisits includPeCP office visits anPdCP house calls and pediatric clinic visit $30 20%- Afterdeductible Retail clinics $30 20%- Afterdeductible Specialists Office visits and house calls renderedabsypecialist. Specialist includes but is not limited to allergists, dermatologists and xxxxxxxxxxXx.xx below for behavioral health specialist. $50 20%- Afterdeductible Office visits and house calls rendered by a behavioral health specialist. $30 20%- Afterdeductible Organ Transplants Organ transplant services 0%- Afterdeductible 20%- Afterdeductible Physical/Occupational Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD 20%- Afterdeductible 40% Aftedr eductible Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. 0%- Afterdeductible 20%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), and notpurchased from a retail, specialty or mail order pharmacy: Injectable drug*s 0%- Afterdeductible 20%- Afterdeductible Infuseddrugs* 0%- Afterdeductible 20%- Afterdeductible Medications other than injected and infused d*rugs Are included in thaellowance for the medical service bein rendered. Are included in thaellowance for the medical service being rendered. Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section fo details. 0% 20%- Afterdeductible Private Duty Nursing Service*s Must be performed by a certified home health care age 0%- Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Respiratory Therapy Inpatient 0%- Afterdeductible 20%- Afterdeductible Outpatient 0%- Afterdeductible 20%- Afterdeductible Skilled Care in a Nursing Facilit*y Skilled or su-bacute care 0%- Afterdeductible 20%- Afterdeductible Speech Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD 20%- Afterdeductible 40%- Afterdeductible Surgery Services Inpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible Outpatientservices - includesphysicianservices and outpatient hospitaolr ambulatorysurgical centerfacility services. 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce. L F L D Q ¶ V 0% 20%- Afterdeductible Telemedicine Services When rendered by a designatepdrovider. $30 Not Covered When rendered by anetworkprovider. $30 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatien,tin a S K o\ ffiVce, uLrgenFt caLre cDenterQor ¶ free-standing laboratory: Major diagnostic imaging and tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans PET scans, nuclear medicine and cardiac imaging. 0%- Afterdeductible 20%- Afterdeductible Sleep studies*. 0%- Afterdeductible 20%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted abov $75 20%- Afterdeductible Lab and pathology services. $25 20%- Afterdeductible Diagnostic colorectal servic-e(sIncluding, but not limited tof,ecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. S Prevention and Early Detection Services for preventive colorectal services.) 0%- Afterdeductible 20%- Afterdeductible Lyme disease diagnosis and treatment $25 20%- Afterdeductible Urgent Care Urgent care services $100 The level of coverage is the same as network xxxxxx.xx Vision Care Services Vision exam- one routine eye exam pemr emberper plan year. $0 20%- Afterdeductible Non-routine eyeexam $0 20%- Afterdeductible SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $150 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible Not Covered teet.h $30 20%- Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility * 0% - After deductible Not 0%- Afterdeductible 20%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0%- Afterdeductible 20%- Afterdeductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatientdurable medical equipmen-t*Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplies-*Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supplpyrovider(other than apharmacy). See the Summary of Pharmacy Benefits for supplies purchased at apharmacy. 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers NetworkProviders Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider.xxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Education - Asthma Asthma management 0% 20%- Afterdeductible Emergency Room Services Hospitalemergencyroom $150 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $30 20%- Afterdeductible Hearing diagnostic testing 0% 20%- Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for amemberunder 19; thebenefit limis $700 per hearing aid for amember19 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services when billed by a home hea care agency. 0%- Afterdeductible 20%- Afterdeductible Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Services Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) D infertility treatment cycles will be coveredplpaenryear with a total of eight (8) infertility treatcmyecnlets covered in a P H liPfetimEe. H U ¶ V 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Inpatient Services General hospitaol r specialty hospitaslervices*- unlimited days 0%- Afterdeductible 20%- Afterdeductible Rehabilitationfacility services-*limited to45 days perplan year. 0%- Afterdeductible 20%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 20%- Afterdeductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. $100 $100** In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$25 20% plus $25 - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 20% - After deductible** Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 20% - After deductible** Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 20% - After deductible** Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 20% - After deductible** Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 20% - After deductible** Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. 20% - After deductible** Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.20% - After deductible**

Dental Services - Accidental Injury (Emergency. Emergency room - room- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $200 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0teet.h $50 20% - After deductible Not Covered Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility outpatientfacility* 00%- Afterdeductible 20% - After deductible Not Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0%- Afterdeductible 20% - Afterdeductible Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and detailsanddetails. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result re of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Early Interveniton Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Education - Asthma Asthma management 0% 20%- Afterdeductible Emergency Room Services Hospitalemergency room $200 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $50 20%- Afterdeductible Hearing diagnostic testing 0% 20%- Afterdeductible Hearing aids- The benefit limit is $2,000 per hearing aid a member under 21, the benefit limit is $700 per hearing for amember 21 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services when billed by a home heal care agency. 0%- Afterdeductible 20%- Afterdeductible Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. LThreFe (3L)-ivniDtro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in Pa H lifetime. 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits anddetails. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient Services General hospitaol r specialtyhospitalservices*- Unlimited Days 0%- Afterdeductible 20%- Afterdeductible Rehabilitationfacility service*s- Limited to 45 days peprlan year. 0%- Afterdeductible 20%- Afterdeductible Physicianhospitalvisits. 0%- Afterdeductible 20%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for deta 0% 20%- Afterdeductible Surgery services- includes mastectomy and reconstructiv surgery. See Mastectomy Services in Section 3 for detai 0% 20%- Afterdeductible Mastectom-yrelated treatmen-t includes protheses and treatment for physical complications. 0% Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible Not Covered 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $50 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible Not Covered teet.h $15 20%- Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility* 0% - After deductible Not 20%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0% 20%- Afterdeductible Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers NetworkProviders Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% 20% - After deductible Not Covered Outpatient medical supplies* - Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% 20% - After deductible Not Covered Outpatient diabetic Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% 20% - After deductible Not Covered Outpatient prosthesis* - Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% 20% - After deductible Not Covered Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% 20% - After deductible Not Covered Afterdeductible Enteral formula or food taken orally * ora*lly 20% - After deductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Education - Asthma Asthma management $15 20% - Afterdeductible Emergency Room Services Hospitalemergencyroom $50 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $15 20% - Afterdeductible Hearing diagnostic testing 0% 20% - Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for a member under 19; thbeenefit limis $700 per hearing aid for a member 19 and older. 20% The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services when billed by a hhoemaleth care agency. 0% 20%- Afterdeductible Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 0% 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) -ivnitDro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in a P H liPfetimEe. H U ¶ V 20% 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Infusion Therapy- Administration Services Outpatient- hospital 0% 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0% 20%- Afterdeductible Inpatient Services General hospitaol r specialtyhospitalservices*- unlimited days 0% 20%- Afterdeductible Rehabilitationfacility service*s- limited to 45 days peprlan year. 0% 20%- Afterdeductible Physicianhospitalvisits 0% 20%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for details. 0% 20%- Afterdeductible Surgery services- includes mastectomy and reconstructi surgery. See Mastectomy Services in Section 3 for deta 0% 20%- Afterdeductible Mastectom-yrelated treatmen-t includes prostheses and treatment for physical complications. 0% Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$50 20% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 20% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - room- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $200 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible teet.h $50 Not Covered Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility outpatientfacility* 0% - After deductible 0%- Afterdeductible Not Covered DialysisServices Inpatient/outpatie/nint your home 0%- Afterdeductible Not Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this servicethisservice. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible 20%- Afterdeductible Not Covered Outpatient medical supplies* - Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible 20%- Afterdeductible Not Covered Outpatient diabetic Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 20%- Afterdeductible Not Covered Outpatient prosthesis* - Outpatientprosthesis*- Must be provided porvided by a licensed medical supply provider. 20% - After deductible 20%- Afterdeductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 20%- Afterdeductible Not Covered Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result re of cancer treatment. 2020%- Afterdeductible The level of coverages tihe same as network xxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network providerxxxxxx.xx Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospitalemergency room $200 The level of coverage is the same as network xxxxxx.xx Experimental andInvestigational Services Coverage varies based on type of service. Hearing Services Hearing exam $50 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids- The benefit limit is $2,000 per hearing aid a member under 21t,he benefit limit is $700 per hearing a for a member 21 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services when billed by a home heal care agency. 0%- Afterdeductible Not Covered Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% Not Covered InfertilityServices* Inpatient/outpatiennt/ia S K o\ ffiVce. LThreFe (3L)-ivniDtro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in Pa H lifetime. 20%- Afterdeductible Not Covered Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible Not Covered In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible Not Covered Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for thisservice. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient Services General hospitaol r specialty hospitaslervices*- Unlimited Days 0%- Afterdeductible Not Covered Rehabilitationfacility service*s- Limited to 45 days peprlan year. 0%- Afterdeductible Not Covered Physicianhospitalvisits. 0%- Afterdeductible Not Covered Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for deta 0% Not Covered Surgery services- includes mastectomy and reconstructiv surgery. See Mastectomy Services in Section 3 for detai 0% Not Covered Mastectom-yrelated treatmen-t includes protheses and treatment for physical complications. 0% Not Covered Office Visits- (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injection-sApplies to injection only, including administration. $0 Not Covered Diabetic Office Visits Podiatrist Service-sFirst routine visit inpalan year $0 Not Covered Vision Care Service-sfirst routine eye exam inpalan yearthat includes a retinal eye exam. $0 Not Covered Hospitalbased clinic visits $50 Not Covered PCP visits- includingbehavioral healthV. isits includPeCP office visits anPdCP house calls and pediatric clinic visits $30 Not Covered Retailclinics $30 Not Covered Specialists Office visits and house calls rendered by a specialis Specialist includes but is not limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. $50 Not Covered Officevisits and house calls rendered by a behaviora health specialist. $30 Not Covered Organ Transplants Organ transplant services 0%- Afterdeductible Not Covered Physical/Occupational Therapy 2 X W S D W L H WQ KWofHfice.U KD R 20%- Afterdeductible Not Covered Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. 0%- Afterdeductible Not Covered Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic Equipment and Supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), an notpurchased from a retail, specialty or mail order pharmacy: Injectable drug*s 0%- Afterdeductible Not Covered Infused drug*s 0%- Afterdeductible Not Covered Medications other than injected and infused *rugs Are included in thaellowance for the medical service bein rendered. Are included in thaellowance for the medical service being rendered. Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for thisservice. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prevention Care Services andEarly Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Service*s Must be performed by a certified home health care agen 0%- Afterdeductible Not Covered Radiation Therapy/Chemotherapy Services Outpatient 0%- Afterdeductible Not Covered In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible Not Covered Respiratory Therapy Inpatient 0%- Afterdeductible Not Covered Outpatient 0%- Afterdeductible Not Covered Skilled Care in a Nursing Facilit*y Skilled or su-bacute care 0%- Afterdeductible Not Covered Speech Therapy Surgery Services* Inpatient physiciasnervices 0%- Afterdeductible Not Covered Outpatientservices- includesphysicianservices and outpatient hospitaolr ambulatory surgical centfearcility services. 0%- Afterdeductible Not Covered In a S K o\ ffiVce L F L D Q ¶ V 0% NotCovered Telemedicine Services When rendered by a designatepdrovider. $30 Not Covered When rendered by anetworkprovider. $30 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatien,tin a S K o\ ffiVce, uLrgenFt caLre cDenterQor ¶ free-standing laboratory: Major diagnostic imaging and tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans, PE scans, nuclear medicine and cardiac imaging. 0%- Afterdeductible Not Covered Sleep studies*. 0%- Afterdeductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above $75 Not Covered Lab and pathology services. $25 Not Covered Diagnostic colorectal servic-e(sIncluding, but not limited tof,ecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. S Prevention and Early Detection Services for preven colorectal services.) 0%- Afterdeductible Not Covered Lyme disease diagnosis and treatment $25 Not Covered Urgent Care Urgent care services $100 The level of coverage is the same as network xxxxxx.xx Vision Care Services Vision exam- One routine eye exam pemr emberper plan year. $0 Not Covered Non-routine eye exam $0 Not Covered PediatricVision Care for members under age 19: See Vision Services in Section 3 for benefit limits and detail These services only apply to an enrolled member under age of 19: Prescription glasses- Frame and lenses 0% Not Covered Contact lens (in lieouf prescription glasses) 0% Not Covered Vision hardware for enrollmedembersaged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$50 20% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered 20% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible Not Covered teet.h 0%- Afterdeductible 40%- Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility* 0% - After deductible Not 0%- Afterdeductible 40%- Afterdeductible Dialysis Services Inpatient/outpatie/nint yourhome 0%- Afterdeductible 40%- Afterdeductible Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - 0%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic 0%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - 0%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 0%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 0%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatmenttreatmnet. 20% - After deductible 0%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Education - Asthma Asthma management 0%- Afterdeductible 40%- Afterdeductible Emergency Room Services Hospitalemergencyroom 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0%- Afterdeductible 40%- Afterdeductible Hearing diagnostic testing 0%- Afterdeductible 40%- Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for a member under 19; thbeenefit limis $700 per hearing aid for a member 19 and older. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services when billed by a home hea care agency. 0%- Afterdeductible 40%- Afterdeductible Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 40%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0%- Afterdeductible 40%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) -ivnitDro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in a P H liPfetimEe. H U ¶ V 0%- Afterdeductible 40%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Inpatient Services General hospitaol r specialtyhospitalservices*- unlimited days 0%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility service*s- limited to 45 days peprlan year. 0%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 40%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for details. 0%- After deductible 40%- Afterdeductible Surgery services- includes mastectomy and reconstructi surgery. See Mastectomy Services in Section 3 for deta 0%- After deductible 40%- Afterdeductible Mastectom-yrelated treatmen-t includes prostheses and treatment for physical complications. 0%- After deductilbe Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - room- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound natural toousndnatural teeth. 0% - After deductible Not Covered 0%- Afterdeductible 40%- Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility outpatientfacility* 0% - After deductible Not 0%- Afterdeductible 40%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0%- Afterdeductible 40%- Afterdeductible Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result re of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Education - Asthma Asthma management 0%- Afterdeductible 40%- Afterdeductible Emergency Room Services Hospitalemergency room 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0%- Afterdeductible 40%- Afterdeductible Hearing diagnostic testing 0%- Afterdeductible 40%- Afterdeductible Hearing aids T–he benefit limis $1,500 per hearing aid fo a member under 19; thbeenefit limis $700 per hearing aid for a member 19 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services whbeinlled by a home health care agency. 0%- Afterdeductible 40%- Afterdeductible Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 40%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0%- Afterdeductible 40%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. LThreFe (3L)-ivniDtro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in Pa H lifetime. 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient Services General hospitaol r specialty hospitaslervices*- Unlimited Days 0%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility service*s- Limited to 45 days peprlan year. 0%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits. 0%- Afterdeductible 40%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for deta 0%- Afterdeductible 40%- Afterdeductible Surgery services- includes mastectomy and reconstructiv surgery. See Mastectomy Services in Section 3 for detai 0%- Afterdeductible 40%- Afterdeductible Mastectom-yrelated treatmen-t includes protheses and treatment for physical complications. 0%- Afterdeductible Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible Not Covered teet.h 20%- Afterdeductible 40%- Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility * 0% - After deductible Not 20%- Afterdeductible 40%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 20%- Afterdeductible 40%- Afterdeductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatientdurable medical equipmen-t*Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplies-*Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supplpyrovider(other than apharmacy). See the Summary of Pharmacy Benefits for supplies purchased at apharmacy. 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider.xxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0%- Afterdeductible The level of coverage is the same as networkprovide.r Education - Asthma Asthma management 20%- Afterdeductible 40%- Afterdeductible Emergency Room Services Hospitalemergencyroom 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Experimental andInvestigational Services Coverage varies based on type of service. Hearing Services Hearing exam 20%- Afterdeductible 40%- Afterdeductible Hearing diagnostic testing 20%- Afterdeductible 40%- Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for amemberunder 19; thebenefit limis $700 per hearing aid for amember19 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skillesdervices when billed by a home health care agency. 20%- Afterdeductible 40%- Afterdeductible Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 20%- Afterdeductible 40%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 20%- Afterdeductible 40%- Afterdeductible Infertility Services Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) D infertility treatment cycles will be coveredplpaenryear with a total of eight (8) infertility treatcmyecnlets covered in a P H liPfetimEe. H U ¶ V 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 20%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 20%- Afterdeductible 40%- Afterdeductible Inpatient Services General hospitaol r specialty hospitaslervices*- unlimited days 20%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility services-*limitedto 45 daysper plan year. 20%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits 20%- Afterdeductible 40%- Afterdeductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$50 20% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. $150 $150 In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$40 20% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Covered Benefits 20% - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered 20% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Flex Plan (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. 20% - After deductible Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.20% - After deductible