Common use of Early Intervention Services Clause in Contracts

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES The level of coverage is the same as network provider. Education Asthma Management 0% YES 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES 40% YES Diagnostic Testing 0% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro cycles will be covered per benefit year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40% YES Hospital based clinic visits for adults 0% YES 40% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES 40% YES PCP does NOT practice with PCMH model of care. 0% YES 40% YES Podiatrist Services Routine foot care is not covered. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details.

Early Intervention Services. (EIS) For children from birth to 36 months. months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES NO 0% The level of coverage is the same as network provider. YES NO The level of coverage is the same as network provider. Education Asthma Management 0% YES $0 NO 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES $40 NO 40% YES Diagnostic Testing 020% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 020% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 40% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES $200 NO The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro infertility treatment cycles will be covered per benefit year with a total of eight (8) in-vitro infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 4020% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 020% YES 40% YES Inpatient Physician Hospital Visits Inpatient 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 020% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES $40 NO 40% YES Hospital based clinic visits for adults 0% YES $40 NO 40% YES House Calls rendered by Primary Care Physician 0% YES personal care physician PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $15 NO For a member nineteen (19) and older $25 NO House Calls rendered by Specialist 0% YES $40 NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pediatric Clinic visit 0% YES PCP practices with PCMH model of care. $15 NO 40% YES Primary PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $15 NO For a member nineteen (19) and older $25 NO Personal Care Physician (PCP) PCP practices with PCMH model of care. 0% YES $15 NO 40% YES PCP does NOT practice with PCMH model of care. 0% YES 40% YES For a member under nineteen (19) $15 NO For a member nineteen (19) and older $25 NO Podiatrist Services Routine foot care is not covered. 0$40 NO 40% YES Specialist Visits Routine and non-routine visits. $40 NO 40% YES Organ Transplants 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 020% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 020% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 020% YES 40% YES Infused drugs 020% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% YES Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1 per benefit year. 0% NO 40% YES Pediatric preventive clinic 0% NO 40% YES Diabetes education Individual and group sessions are covered. 0% NO 40% YES Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 40% YES Adult Immunization 0% NO 40% YES Pediatric Immunization 0% NO 40% YES Travel Immunization 0% NO 40% YES Allergy injections Applies to injection only including administration. 20% YES 40% YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Outpatient 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Chemotherapy Services In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services . 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office 0% NO 40% YES Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free- standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? For tests, imaging and lab, other than the diagnostic imaging services listed above. 20% YES 40% YES Diagnostic Including, but not limited colorectal to, fecal occult blood services testing, flexible sigmoidoscopy, colonoscopy, and barium enema. 20% YES 40% YES See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. Lyme Disease- Diagnosis/ Treatment 20% YES 40% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $75 NO The level of coverage is the same as network provider. Vision care services Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Eye Exam In a doctor’s office One routine eye exam per benefit year, including one pediatric vision exam for a member up to age 19. $40 NO 40% YES Medically necessary eye exams are covered. Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. 0% NO Not Covered Not Covered Non-collection prescription frames are NOT covered. One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% NO Not Covered Not Covered The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. • Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department Depart- ment of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES The level of coverage is the same as network provider. Education Asthma Management 0% YES 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES 40% YES Diagnostic Testing 0% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro infertility treatment cycles will be covered per benefit plan year with a total of eight (8) in-vitro infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit plan year. 0% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40% YES Hospital based clinic visits for adults 0% YES 40% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model Sick Visit. See Prevention and Early Detection Services for coverage of care. 0% YES 40% YES PCP does NOT practice with PCMH model of careannual preventive office visit. 0% YES 40% YES Podiatrist Services Routine foot care is not covered. 0% YES 40% YES Specialist Visits Routine and non-routine visits. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 0% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES The level of coverage is the same as network provider. Education Asthma Management 0% YES 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES 40% YES Diagnostic Testing 0% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro infertility treatment cycles will be covered per benefit plan year with a total of eight (8) in-vitro infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit plan year. 0% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40% YES Hospital based clinic visits for adults 0% YES 40% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model Sick Visit. See Prevention and Early Detection Services for coverage of care. 0% YES 40% YES PCP does NOT practice with PCMH model of careannual preventive office visit. 0% YES 40% YES Podiatrist Services Routine foot care is not covered. 0% YES 40% YES Specialist Visits Routine and non-routine visits. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 0% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% NO The level of coverage is the same as Tier 1 network provider. YES provider The level of coverage is the same as Tier 1 network provider. provider Education Asthma Management Manage- ment 0% YES 40NO 0% NO 60% YES Experimental/ Investigational Experimental /Investiga- tional Services Coverage varies based on type of service. See Section 3.12. Hearing Hearing Exam 0% YES 40Exam^ $30 NO $50 NO 60% YES Diagnostic Testing 020% YES 4020% YES 60% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 020% YES The level of coverage is the same as Tier 1 network provider. provider The level of coverage is the same as Tier 1 network provider Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 020% YES 4020% YES 60% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 4020% YES 60% YES Hospice Care Inpatient/in Inpatient/ In your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 4020% YES 60% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES Emergency $200 NO The level of coverage is the same as network providerTier 1. Service Service Type, Provider, or Place The level of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay coverage is the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro cycles will be covered per benefit year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40% YES Hospital based clinic visits for adults 0% YES 40% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES 40% YES PCP does NOT practice with PCMH model of care. 0% YES 40% YES Podiatrist Services Routine foot care is not covered. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for detailssame as Tier 1.

Early Intervention Services. (EIS) For children from birth to 36 months. months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES The level of coverage is the same as network provider. Education Asthma Management 010% YES 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 010% YES 40% YES Diagnostic Testing 010% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 010% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 10% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 010% YES 40% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 010% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 010% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 10% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro cycles will be covered per benefit year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 010% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 010% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 010% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 010% YES 40% YES Inpatient Physician Hospital Visits Inpatient 10% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 010% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 010% YES 40% YES Hospital based clinic visits for adults 010% YES 40% YES House Calls rendered by Primary Care Physician 010% YES 40% YES House Calls rendered by Specialist 010% YES 40% YES Pediatric Clinic visit 010% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model Sick Visit. See Prevention and Early Detection Services for coverage of careannual preventive office visit. 0% YES 40% YES PCP does NOT practice with PCMH model of care. 010% YES 40% YES Podiatrist Services Routine foot care is not covered. 010% YES 40% YES Specialist Visits Routine and non- routine visits. 10% YES 40% YES Organ Transplants 10% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 010% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 010% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 010% YES 40% YES Infused drugs 10% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman One (1) routine annual preventive gynecological visit examination per benefit year per female 0% NO 40% YES member will be covered. Pediatric Well-Child Office preventive office Visits: visit Birth - 35 months:11 visits; 0% NO 40% YES 36 months - 19 years: 1 per benefit year. Pediatric preventive clinic 0% NO 40% YES Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription 0% NO 40% YES drugs, see the Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Pediatric Immunization 0% NO 40% YES Travel Immunization 0% NO 40% YES Allergy injections Applies to injection only including administration. 10% YES 40% YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 40% YES Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Benefits. Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing 10% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 10% YES 40% YES In a doctor’s office 10% YES 40% YES Respiratory Therapy 10% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 10% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 10% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at Surgery Services Inpatient 10% YES 40% YES Outpatient 10% YES 40% YES In a Retaildoctor’s office 10% YES 40% YES Tests, SpecialtyImaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care center, or Mail Order Pharmacy free- standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. 10% YES 40% YES For tests, imaging and lab, other than the diagnostic imaging services listed above. 10% YES 40% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 10% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Lyme Disease- Diagnosis/ Treatment 10% YES 40% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 10% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, with diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 10% YES 40% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% YES Not Covered Not Covered Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 covered. The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% YES Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for detailswhich preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES The level of coverage is the same as network provider. Education Asthma Management 015% YES 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 015% YES 40% YES Diagnostic Testing 015% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 015% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 015% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 015% YES 40% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 015% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 015% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 015% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro infertility treatment cycles will be covered per benefit plan year with a total of eight (8) in-vitro infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 015% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 015% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 015% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 015% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 015% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit plan year. 015% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 015% YES 40% YES Hospital based clinic visits for adults 015% YES 40% YES House Calls rendered by Primary Care Physician 015% YES 40% YES House Calls rendered by Specialist 015% YES 40% YES Pediatric Clinic visit 015% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model Sick Visit. See Prevention and Early Detection Services for coverage of careannual preventive office visit. 0% YES 40% YES PCP does NOT practice with PCMH model of care. 015% YES 40% YES Podiatrist Services Routine foot care is not covered. 015% YES 40% YES Specialist Visits Routine and non-routine visits. 15% YES 40% YES Organ Transplants 15% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 015% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 015% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 015% YES 40% YES Infused drugs 15% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 0% NO 40% YES Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 40% YES Pediatric preventive clinic 0% NO 40% YES Diabetes education Individual and group sessions are covered. 0% NO 40% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 40% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 40% YES Adult Immunization 0% NO 40% YES Pediatric Immunization 0% NO 40% YES Travel Immunization 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Allergy injections Applies to injection only including administration. 15% YES 40% YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing 15% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 15% YES 40% YES In a doctor’s office 15% YES 40% YES Respiratory Therapy 15% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 15% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 15% YES 40% YES Surgery Services Inpatient 15% YES 40% YES Outpatient 15% YES 40% YES In a doctor’s office 15% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a RetailDoctor’s office, Specialtyurgent care center, or Mail Order Pharmacy free-standing laboratory Applies to the following diagnostic imaging services:  MRI;  MRA;  CAT scans;  CTA scans;  PET scans; and  Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. 15% YES 40% YES For tests, imaging and lab, other than the diagnostic imaging services listed above. 15% YES 40% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services – Preventive Screening for preventive colorectal services. 15% YES 40% YES Lyme Disease- Diagnosis/ Treatment 15% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Urgent care facility Urgent care facility/walk-in See Section 8.0 – definition of urgent care center. 15% YES The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. 15% YES 40% YES Medically necessary eye exams are covered. Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 One pair of collection prescription frames per plan year. 15% YES Not Covered Not Covered Non-collection prescription frames are NOT covered. One pair of glass or plastic lenses per plan year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 15% YES Not Covered Not Covered The following lens treatments are covered:  UV treatment; 15% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services Vision Hardware for a member under the age of 19  Tint (fashion, gradient, and glass- grey)  Standard plastic scratch coating;  Standard polycarbonate;  Photocromatic/ transitions plastic. One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered.  Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan year. 15% YES Not Covered Not Covered  Daily Wear Disposable are covered up to the benefit limit of a 15% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services Vision care services Vision Hardware for a member under the age of 19 Vision Hardware for a member under the age of 19 three (3) month supply of daily disposable lenses in a plan year.  Conventional contact lens are covered one per plan year. 15% YES Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. 15% YES Not Covered Not Covered Preauthorization recommended. SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for detailswhich preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES The level of coverage is the same as network provider. Education Asthma Management 0% YES 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES 40% YES Diagnostic Testing 0% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hearing Hearing Exam 0% YES 40% YES Diagnostic Testing 0% YES 40% YES Hearing Aids A maximum benefit of $1,500 per hearing aid for a member under 19; A maximum benefit of $700 per hearing aid for a member 19 and older. 20% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per plan year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro cycles will be covered per benefit year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit plan year. 0% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40% YES Hospital based clinic visits for adults 0% YES 40% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES 40% YES PCP does NOT practice with PCMH model of care. 0% YES 40% YES Podiatrist Services Routine foot care is not covered. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES 40% YES PCP does NOT practice with PCMH model of care. 0% YES 40% YES Podiatrist Services Routine foot care is not covered. 0% YES 40% YES Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- non-routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 0% NO 40% YES Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 40% YES Pediatric preventive clinic 0% NO 40% YES Diabetes education Individual and group sessions are covered. 0% NO 40% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 40% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 40% YES Adult Immunization 0% NO 40% YES Pediatric Immunization 0% NO 40% YES Travel Immunization 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Allergy injections Applies to injection only including administration. 0% YES 40% YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES Contraceptive and Sterilization Services for women Prescription Drugs Purchased drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a Retailpharmacy, Specialtysee the Summary of Pharmacy Benefits. 0% NO 40% YES Service Service Type, Provider, or Mail Order Pharmacy Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing 0% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 40% YES In a doctor’s office 0% YES 40% YES Respiratory Therapy 0% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES 40% YES Surgery Services Inpatient 0% YES 40% YES Outpatient 0% YES 40% YES In a doctor’s office 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 for details. 0% YES Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 0% YES 40% YES Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Lab and pathology services 0% YES 40% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services – Preventive Screening for preventive colorectal services. 0% YES 40% YES Lyme Disease- Diagnosis/ Treatment 0% YES 40% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 – definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES 40% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 One pair of collection prescription frames per plan year. 0% YES Not Covered Not Covered Non-collection prescription frames are NOT covered. One pair of glass or plastic lenses per plan year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% YES Not Covered Not Covered The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan year. 0% YES Not Covered Not Covered • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? • Conventional contact lens are covered one per plan year. 0% YES Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% YES Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for detailswhich preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES NO The level of coverage is the same as network provider. Education Asthma Management 0% YES 40NO 20% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES 40$30 NO 20% YES Diagnostic Testing 0% YES 4020% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 020% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 4020% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES $100 NO The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 4020% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro infertility treatment cycles will be covered per benefit plan year with a total of eight (8) in-vitro infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 4020% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 4020% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 4020% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit plan year. 0% YES 4020% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40$30 NO 20% YES Hospital based clinic visits for adults 0% YES 40$30 NO 20% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES 40$10 NO 20% YES PCP does NOT practice with PCMH model of care. 0% YES 40% YES Podiatrist Services Routine foot care is not covered. 0% YES 40For a member under nineteen (19) $10 NO For a member nineteen (19) and older $20 NO House Calls rendered by Specialist $30 NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for detailsPediatric Clinic visit PCP practices with PCMH model of care. 0$10 NO 20% YES 40PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $10 NO For a member nineteen (19) and older $20 NO Primary Care Physician (PCP) PCP practices with PCMH model of care. $10 NO 20% YES PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $10 NO For a member nineteen (19) and older $20 NO Podiatrist Services Routine foot care is not covered. $30 NO 20% YES Specialist Visits Routine and non- non-routine visits. 0% YES 40$30 NO 20% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 4020% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 20% YES 20% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 20% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 20% YES Infused drugs 0% YES 20% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 20% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 0% NO 20% YES Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 20% YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 20% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office 0% NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory Applies to the following diagnostic imaging services:  MRI;  MRA;  CAT scans;  CTA scans;  PET scans; and  Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. 0% YES 20% YES For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES 20% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES 20% YES Lyme Disease- Diagnosis/ Treatment 0% YES 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $50 NO The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. $30 NO 20% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 One pair of collection prescription frames per plan year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per plan year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services Vision Hardware for a member under the age of 19 The following lens treatments are covered:  UV treatment;  Tint ( fashion, gradient, and glass- grey)  Standard plastic scratch coating;  Standard polycarbonate;  Photocromatic/ transitions plastic 0% NO Not Covered Not Covered One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered.  Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan year. 0% NO Not Covered Not Covered  Daily Wear Disposable are 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services Vision Hardware for a member under the age of 19 covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year.  Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. 0% NO Not Covered Not Covered Preauthorization recommended. SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES NO The level of coverage is the same as network provider. Education Asthma Management 0% YES 40NO 20% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES 40$30 NO 20% YES Diagnostic Testing 0% YES 4020% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 020% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 4020% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES $100 NO The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 4020% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro infertility treatment cycles will be covered per benefit plan year with a total of eight (8) in-vitro infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 4020% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 4020% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit plan year. 0% YES 4020% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40$30 NO 20% YES Hospital based clinic visits for adults 0% YES 40$30 NO 20% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES 40$10 NO 20% YES PCP does NOT practice with PCMH model of care. 0$20 NO House Calls rendered by Specialist $30 NO 20% YES 40Pediatric Clinic visit PCP practices with PCMH model of care. $10 NO 20% YES Podiatrist Services Routine foot care is not coveredPCP does NOT practice with PCMH model of care. 0% YES 40$20 NO Primary Care Physician (PCP) First non-preventive office visit in the plan year rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per plan year. $0 NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Subsequent non- preventive office visits in the plan year - PCP practices with PCMH model of care. $10 NO Subsequent non- preventive office visits in the plan year - PCP does not practice with PCMH model of care. $20 NO Retail Clinics See Section 3.23 – Office Visits for details. 0$20 NO 20% YES 40Podiatrist Services Routine foot care is not covered. $30 NO 20% YES Specialist Visits Routine and non- non-routine visits. 0% YES 40$30 NO 20% YES Organ Transplants 0% YES 4020% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 020% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 4020% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 20% YES Infused drugs 0% YES 20% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% NO The level of coverage is the same as Tier 1 network provider. YES The level of coverage is the same as Tier 1 network provider. Education Asthma Management 0% YES 40NO 0% NO 50% YES Experimental/ Investigational Investiga- tional Services Coverage varies based on type of service. See Section 3.12. Hearing Hearing Exam 0% YES 40Exam^ $30 NO $50 NO 50% YES Diagnostic Testing 0% YES 400% YES 50% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 020% YES The level of coverage is the same as Tier 1 network provider. The level of coverage is the same as Tier 1 network provider. Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 400% YES 50% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 400% YES 50% YES Hospice Care Inpatient/in Inpatient/ In your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 400% YES 50% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES Emergency $200 NO The level of coverage is the same as network providerTier 1. Service Service Type, Provider, or Place The level of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay coverage is the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro cycles will be covered per benefit year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40% YES Hospital based clinic visits for adults 0% YES 40% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES 40% YES PCP does NOT practice with PCMH model of care. 0% YES 40% YES Podiatrist Services Routine foot care is not covered. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Retail Clinics See Section 3.23 – Office Visits for details. 0% YES 40% YES Specialist Visits Routine and non- routine visits. 0% YES 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for detailssame as Tier 1.

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES NO The level of coverage is the same as network provider. Education Asthma Management 0% YES NO 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES 40% YES Diagnostic Testing 0% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $30 NO 40% YES Diagnostic Testing 0% YES 40% YES Hearing Aids A maximum benefit of $1,500 per hearing aid for a member under 19; A maximum benefit of $700 per hearing aid for a member 19 and older. 20% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES $150 NO The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro infertility treatment cycles will be covered per benefit plan year with a total of eight (8) in-vitro infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 40% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Infusion Therapy (continued) In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 40% YES Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit plan year. 0% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES $30 NO 40% YES Hospital based clinic visits for adults 0% YES $30 NO 40% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES $15 NO 40% YES PCP does NOT practice with PCMH model of care. 0% YES $25 NO House Calls rendered by Specialist $30 NO 40% YES Podiatrist Services Routine foot care is not coveredPediatric Clinic visit PCP practices with PCMH model of care. 0% YES $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Primary Care Physician (PCP) First non-preventive office visit in the plan year rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per plan year. $0 NO 40% YES Subsequent non- preventive office visits in the plan year - PCP practices with PCMH model of care. $15 NO Subsequent non- preventive office visits in the plan year - PCP does not practice with PCMH model of care. $25 NO Retail Clinics See Section 3.23 – Office Visits for details. 0$25 NO 40% YES Podiatrist Services Routine foot care is not covered. $30 NO 40% YES Specialist Visits Routine and non- non-routine visits. 0% YES $30 NO 40% YES Organ Transplants 0% YES 40% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 020% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 0% NO 40% YES Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 40% YES Pediatric preventive clinic 0% NO 40% YES Diabetes education Individual and group sessions are covered. 0% NO 40% YES Nutritional counseling Unlimited visits per plan year when prescribed by a Retailphysician. 0% NO 40% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, Specialty, or Mail Order Pharmacy See see the Summary of Pharmacy Benefits Benefits. 0% NO 40% YES Adult Immunization 0% NO 40% YES Pediatric Immunization 0% NO 40% YES Travel Immunization 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Allergy injections Applies to injection only including administration. 0% YES 40% YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for details.gestational diabetes, and human papillomavirus. 0% NO 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 40% YES In a doctor’s office 0% YES 40% YES Respiratory Therapy 0% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 40% YES Outpatient 0% YES 40% YES In a doctor’s office $10 NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply?

Early Intervention Services. (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES NO The level of coverage is the same as network provider. Education Asthma Management 0% YES 40NO 20% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES 40$30 NO 20% YES Diagnostic Testing 0% YES 4020% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 020% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES 4020% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES $100 NO The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) in-vitro infertility treatment cycles will be covered per benefit plan year with a total of eight (8) in-vitro infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES 4020% YES Infusion Therapy Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES 4020% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES 4020% YES Inpatient Physician Hospital Visits Inpatient 0% YES 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 0% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit plan year. 0% YES 4020% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES 40$30 NO 20% YES Hospital based clinic visits for adults 0% YES 40$30 NO 20% YES House Calls rendered by Primary Care Physician 0% YES 40% YES House Calls rendered by Specialist 0% YES 40% YES Pediatric Clinic visit 0% YES 40% YES Primary Care Physician (PCP) PCP practices with PCMH model of care. 0% YES 40$10 NO 20% YES PCP does NOT practice with PCMH model of care. 0For a member under nineteen (19) $10 NO For a member nineteen (19) and older $20 NO House Calls rendered by Specialist $30 NO 20% YES 40Pediatric Clinic visit PCP practices with PCMH model of care. $10 NO 20% YES Podiatrist Services Routine foot care is not coveredPCP does NOT practice with PCMH model of care. 0% YES 40% YES For a member under nineteen (19) $10 NO For a member nineteen (19) and older $20 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) Primary Care Physician (continuedPCP) Retail Clinics See Section 3.23 – Office Visits for detailsPCP practices with PCMH model of care. 0$10 NO 20% YES 40PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $10 NO For a member nineteen (19) and older $20 NO Podiatrist Services Routine foot care is not covered. $30 NO 20% YES Specialist Visits Routine and non- non-routine visits. 0% YES 40$30 NO 20% YES Organ Transplants 0% YES 4020% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 020% YES 4020% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 40% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 40% YES Infused drugs 0% YES 4020% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES 20% YES Infused drugs 0% YES 20% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details.