Common use of Emergency Room Benefits Clause in Contracts

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 30% 30% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 30% $100 per visit plus 30% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) $250 per admission plus 30% $250 per admission plus 30% 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contracep- tives) 30% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 30% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational therapist. 30% Not covered 13 Medical supplies 30% Not covered 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care You pay nothing Not covered 14 Pre-hospice consultation You pay nothing Not covered 14 Routine home care You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits (Facility Services) Inpatient Emergency Facility Services $250 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services You pay nothing 50% Residential care for Mental Health Condition $250 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 per visit 50% Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 30% 30% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 30% $100 per visit plus 30% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) $250 per admission plus 30% $250 per admission plus 30% 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contracep- tives) 30% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 30% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational therapist. 30% Not covered 13 Medical supplies 30% Not covered 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care You pay nothing Not covered 14 Pre-hospice consultation You pay nothing Not covered 14 Routine home care You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits (Facility Services) Inpatient Emergency Facility Services $250 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Sub acute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Sub acute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 35 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 16, 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up to $500 per day 18 day18 Inpatient Professional services You pay nothing 50% Residential care for Mental Health Condition $250 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 35 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 35 per visit 50% Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 30% 30% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 30% $100 per visit plus 30% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) $250 per admission plus 30% $250 per admission plus 30% 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contracep- tives) 30% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 30% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational therapist. 30% Not covered 13 Medical supplies 30% Not covered 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care You pay nothing Not covered 14 Pre-hospice consultation You pay nothing Not covered 14 Routine home care You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits (Facility Services) Inpatient Emergency Facility Services $250 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Sub acute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Sub acute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 35 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 16, 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up to $500 per day 18 day18 Inpatient Professional services You pay nothing 50% Residential care for Mental Health Condition $250 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 35 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 35 per visit 50% Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 3035% 3035% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 3035% $100 per visit plus 3035% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) $250 per admission plus 3035% $250 per admission plus 3035% 11 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 12 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility benefit bene- fit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contracep- tivescontra- ceptives) 3035% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 3035% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 3035% Not covered Vasectomy 3035% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Cal- endar Year for all Home Health and Home Infusion/Home Injectable ServicesSer- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational occupational therapist. 3035% Not covered 13 12 Medical supplies 3035% Not covered 13 12 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Calendar Year for all Home Health and Home Infusion/Home Injectable ServicesSer- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 3035% Not covered 13 12 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Inject- able Services Calendar Year visit limitation.) 3035% Not covered 13 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 3035% Not covered 14 13 General Inpatient care 3035% Not covered 14 13 Inpatient Respite Care You pay nothing Not covered 14 13 Pre-hospice consultation You pay nothing Not covered 14 13 Routine home care You pay nothing Not covered 14 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits (Facility Services) Inpatient Emergency Facility Services $250 per admission plus 3035% $250 per admission plus 3035% 15 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and suppliessup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Bariatric Surgery Benefits for Residents of Designated Counties in California sec- tionsection. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 3035% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing FacilityFacili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 3035% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 3035% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory la- boratory services 3035% 50% of up to $500 per day 15 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 3035% 50% of up to $300 per day 15 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 3035% 50% of up to $500 per day 15 14 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy chem- otherapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 3035% 50% of up to $500 per day 15 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 3035% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 3035% 50% of up to $500 per day 15 14 Office location $45 per visit 35% 50% Outpatient department of a Hospital $250 per surgery plus 3035% 50% of up to $500 per day 15 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 17 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Providers 16 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 3035% 50% of up $500 per day 18 Inpatient Professional services You pay nothing 35% 50% Residential care for Mental Health Condition $250 per admission plus 3035% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 3035% 50% Behavioral Health Treatment in an office setting 3035% 50% Electroconvulsive Therapy (ECT) 19 3018 35% 50% Intensive Outpatient Program 19 3018 35% 50% Partial Hospitalization Program 20 3019 35% per episode 50% of up to $500 per day day18 Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 3035% 50% Transcranial magnetic stimulation 3035% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 per visit 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics or- thotics Services. Office visits $45 per visit 35% 50% Orthotic equipment and devices 3035% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 23, 24 Participating Pharmacy 24 25 Non-Participating Pharmacy 2526 Retail Prescriptions Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 35% Not covered Podiatric Benefits Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Care Benefits 31 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at the applicable Pre- ferred denied and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. 30% 30% You pay nothing Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at denied and the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. $100 per visit plus 30% $100 per visit plus 30% Emergency room Services resulting in admission (billed Billed as part of Inpa- tient Inpatient Hospital Services) $250 100 per admission plus 30% $250 per admission plus 30% 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning and Infertility Benefits 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc.), the facility Copayment listed under the appropriate facility benefit Benefit in the Summary this Sum- xxxx of Benefits will also apply, except for insertion and/or removal of intrauter- ine device (IUD), intrauterine device (IUD), and tubal ligation. Counseling and consulting (Including Physician office visits for diaphragm fitting fitting, injectable contraceptives, or injectable contracep- tivesimplantable contraceptives) 30% Not covered You pay nothing Diaphragm fitting procedure When administered You pay nothing Elective abortion $100 per surgery Implantable contraceptives You pay nothing Infertility Services Diagnosis and treatment of cause of Infertility (in an office location, this is in addition to the Physician office visit Copayment. 30vitro fertili- zation and artificial insemination not covered) 50% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered You pay nothing Insertion and/or removal of intrauterine device (IUD) You pay nothing Intrauterine device (IUD) You pay nothing Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered You pay nothing Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 $50 per surgery Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Benefits4 Home health care agency Services, Services (including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational occupational therapist) Up to a maximum of 100 visits per Calendar Year per Member by home health care agency providers. 30% Not covered 13 You pay nothing Medical supplies 30% Not covered 13 and laboratory Services You pay nothing Benefit Member Copayment Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider Hemophilia Infusion Provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/You pay nothing Hemophilia therapy home intravenous injectable therapy infusion nursing visit provided by a Home Hemophilia Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under Provider and prior authorized by the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse Plan (Home infusion agency nursing Nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care You pay nothing Not covered 14 Pre-hospice consultation You pay nothing Not covered 14 Routine home care You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits (Facility Services) Inpatient Emergency Facility Services $250 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services You pay nothing 50% Residential care for Mental Health Condition $250 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 per visit 50% Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25nothing

Emergency Room Benefits. Emergency room Room Physician Services services Note: After Services services have been provided, Blue Shield may conduct con- duct a retro- spective retrospective review. If this review determines that Services ser- vices were provided for a medical condition that a person would not have reasonably believed was an emergency medical conditioncondi- tion, Benefits will be paid at the applicable Pre- ferred and Participating or Non-Preferred Participating Provider levels as specified under Outpatient Physician Services Benefit in the Professional Profes- sional (Physician) Benefits Benefits, “Outpatient Physician services, other than an office setting” in this Summary of Benefits and will be subject to any Calendar Year medical DeductibleBenefits. 3020% 3020% Emergency room Services Room services not resulting in admission Note: After Services services have been provided, Blue Shield may conduct con- duct a retro- spective retrospective review. If this review determines that Services ser- vices were provided for a medical condition that a person would not have reasonably believed was an emergency medical conditioncondi- tion, Benefits will be paid at the applicable Pre- ferred and Participating or Non-Preferred Participating Provider levels as specified under Hospital Bene- fits Benefits (Facility Services), “Outpatient Services services for treatment of illness or inju- ryinjury, radiation therapy, chemotherapy and necessary supplies neces- sary supplies” in this Summary of Benefits and will be subject to any Calendar Year medical DeductibleBenefits. $100 per visit plus 3020% $100 per visit plus 3020% Emergency room Services Room services resulting in admission (billed as part of Inpa- tient inpatient Hospital Servicesservices) $250 100 per admission plus 3020% $250 100 per admission plus 3020% 11 Benefit Member Copayment 4 3 Services by Preferred, Participating, and Other Providers 5 4 Services by Non-Preferred Pre- ferred and Non-Participating Partici- pating Providers 6 5 Family Planning Benefits 12 Benefits1, 7 Note: Copayments listed in this section are for Outpatient Physician Services outpatient Physi- cian services only. If Services services are performed at a facility (HospitalHospi- tal, Ambulatory Surgery Center, etc.), the facility Copayment listed under the appropriate applicable facility benefit in the Summary of Benefits will also apply, except for insertion and/or removal of intrauterine device (IUD), an intrauterine device (IUD), and tubal ligation. Counseling and consulting (Including Physician office visits visit for diaphragm fitting fitting, injectable contraceptives or injectable contracep- tivesimplantable contraceptives.) 30% You pay nothing Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 30% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational therapist. 30% Not covered 13 Medical supplies 30% Not covered 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care You pay nothing Not covered 14 Pre-hospice consultation Implantable contraceptives You pay nothing Not covered 14 Routine home care Injectable contraceptives You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits Insertion and/or removal of intrauterine device (Facility ServicesIUD) Inpatient Emergency Facility Services $250 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services You pay nothing 50Not covered Intrauterine device (IUD) You pay nothing Not covered Tubal ligation You pay nothing Not covered Vasectomy 20% Residential care for Mental Health Condition $250 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 per visit 50% Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25Not covered

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at the applicable Pre- ferred denied and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. 30% 30% You pay nothing Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at denied and the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. $100 per visit plus 30% $100 per visit plus 30% Emergency room Services resulting in admission (billed Billed as part of Inpa- tient Inpatient Hospital Services) $250 per admission plus 30% $250 per admission plus 30% 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 You pay nothing Family Planning and Infertility Benefits 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc.), the facility Copayment listed under the appropriate facility benefit Benefit in the Summary this Sum- xxxx of Benefits will also apply, except for insertion and/or removal of intrauter- ine device (IUD), intrauterine device (IUD), and tubal ligation. Counseling and consulting (Including Physician office visits for diaphragm fitting fitting, injectable contraceptives, or injectable contracep- tivesimplantable contraceptives) 30% Not covered You pay nothing Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 30% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational therapist. 30% Not covered 13 Medical supplies 30% Not covered 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care You pay nothing Not covered 14 Pre-hospice consultation Elective abortion $100 per surgery Implantable contraceptives You pay nothing Not covered 14 Routine home care Infertility Services Diagnosis and treatment of cause of Infertility (in vitro fertili- zation and artificial insemination not covered) 50% Injectable contraceptives You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits Insertion and/or removal of intrauterine device (Facility ServicesIUD) Inpatient Emergency Facility Services $250 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services You pay nothing 50% Residential care for Mental Health Condition Intrauterine device (IUD) You pay nothing Tubal ligation You pay nothing Vasectomy $250 75 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 per visit 50% Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25surgery

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 3035% 3035% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 3035% $100 per visit plus 3035% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) $250 per admission plus 3035% $250 per admission plus 3035% 11 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 12 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility benefit bene- fit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contracep- tivescontra- ceptives) 3035% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 3035% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 3035% Not covered Vasectomy 3035% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Cal- endar Year for all Home Health and Home Infusion/Home Injectable ServicesSer- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational occupational therapist. 3035% Not covered 13 12 Medical supplies 3035% Not covered 13 12 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Calendar Year for all Home Health and Home Infusion/Home Injectable ServicesSer- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 3035% Not covered 13 12 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Inject- able Services Calendar Year visit limitation.) 3035% Not covered 13 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 3035% Not covered 14 13 General Inpatient care 3035% Not covered 14 13 Inpatient Respite Care You pay nothing Not covered 14 13 Pre-hospice consultation You pay nothing Not covered 14 13 Routine home care You pay nothing Not covered 14 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits (Facility Services) Inpatient Emergency Facility Services $250 per admission plus 3035% $250 per admission plus 3035% 15 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and suppliessup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Bariatric Surgery Benefits for Residents of Designated Counties in California sec- tionsection. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 3035% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing FacilityFacili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 3035% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 3035% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory la- boratory services 3035% 50% of up to $500 per day 15 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 3035% 50% of up to $300 per day 15 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 3035% 50% of up to $500 per day 15 14 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy chem- otherapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 3035% 50% of up to $500 per day 15 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated stated, and orthognathic surgery for skeletal deform- ity de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 3035% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 3035% 50% of up to $500 per day 15 14 Office location $45 per visit 35% 50% Outpatient department of a Hospital $250 per surgery plus 3035% 50% of up to $500 per day 15 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 17 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 16 Inpatient Mental Health Services 15, 16 Inpatient Hospital services $250 per admission plus 3035% 50% of up to $500 per day 18 17 Inpatient Professional services You pay nothing 35% 50% Residential care for Mental Health Condition $250 per admission plus 3035% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 3035% 50% Behavioral Health Treatment in an office setting 3035% 50% Electroconvulsive Therapy (ECT) 19 3018 35% 50% Intensive Outpatient Program 19 3018 35% 50% Partial Hospitalization Program 20 3019 35% per episode 50% of up to $500 per day day, per episode Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 3035% 50% Transcranial magnetic stimulation 3035% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 per visit 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics or- thotics Services. Office visits $45 per visit 35% 50% Orthotic equipment and devices 3035% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 20, 21, 22, 23 22 Participating Pharmacy 24 23 Non-Participating Pharmacy 2524

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 30% 30% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 30% $100 per visit plus 30% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) $250 per admission plus 30% $250 per admission plus 30% 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contracep- tives) 30% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 30% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational therapist. 30% Not covered 13 Medical supplies 30% Not covered 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care You pay nothing Not covered 14 Pre-hospice consultation You pay nothing Not covered 14 Routine home care You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits (Facility Services) Inpatient Emergency Facility Services $250 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 40 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 16, 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services You pay nothing 50% Residential care for Mental Health Condition $250 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic di- agnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. Benefits 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 40 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 40 per visit 50% Not covered Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Not covered Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at the applicable Pre- ferred denied and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. 30% 30% You pay nothing Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at denied and the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. $100 per visit plus 30% $100 per visit plus 30% Emergency room Services resulting in admission (billed Billed as part of Inpa- tient Inpatient Hospital Services) $250 500 per admission plus 30% $250 per admission plus 30% 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning and Infertility Benefits 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc.), the facility Copayment listed under the appropriate facility benefit Benefit in the Summary this Sum- xxxx of Benefits will also apply, except for insertion and/or removal of intrauterine device (IUD), intrauterine device (IUD), and tubal ligation. Counseling and consulting (Including Physician office visits for diaphragm fitting fitting, injectable contraceptives, or injectable contracep- tivesimplantable contraceptives) 30% Not covered You pay nothing Diaphragm fitting procedure When administered You pay nothing Elective abortion $100 per surgery Implantable contraceptives You pay nothing Infertility Services Diagnosis and treatment of cause of Infertility (in an office location, this is in addition to the Physician office visit Copayment. 30vitro fertiliza- tion and artificial insemination not covered) 50% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered You pay nothing Insertion and/or removal of intrauterine device (IUD) You pay nothing Intrauterine device (IUD) You pay nothing Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered You pay nothing Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 $75 per surgery Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Benefits4 Home health care agency Services, Services (including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational occupational therapist) Up to a maximum of 100 visits per Calendar Year per Member by home health care agency providers. 30% Not covered 13 $20 per visit Medical supplies 30% Not covered 13 and laboratory Services You pay nothing Benefit Member Copayment Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider Hemophilia Infusion Provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/You pay nothing Hemophilia therapy home intravenous injectable therapy infusion nursing visit provided by a Home Hemophilia Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under Provider and prior authorized by the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse Plan (Home infusion agency nursing Nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care You pay nothing Not covered 14 Pre-hospice consultation You pay nothing Not covered 14 Routine home care You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits (Facility Services) Inpatient Emergency Facility Services $250 20 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services You pay nothing 50% Residential care for Mental Health Condition $250 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 per visit 50% Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25visit

Emergency Room Benefits. Emergency room Room Physician Services services Note: After Services services have been provided, Blue Shield may conduct con- duct a retro- spective retrospective review. If this review determines that Services ser- vices were provided for a medical condition that a person would not have reasonably believed was an emergency medical conditioncondi- tion, Benefits will be paid at the applicable Pre- ferred and Participating or Non-Preferred Participating Provider levels as specified under Outpatient Physician Services Benefit in the Professional Profes- sional (Physician) Benefits Benefits, “Outpatient Physician services, other than an office setting” in this Summary of Benefits and will be subject to any Calendar Year medical DeductibleBenefits. 3010% 3010% Emergency room Services Room services not resulting in admission admission1 Note: After Services services have been provided, Blue Shield may conduct con- duct a retro- spective retrospective review. If this review determines that Services ser- vices were provided for a medical condition that a person would not have reasonably believed was an emergency medical conditioncondi- tion, Benefits will be paid at the applicable Pre- ferred and Participating or Non-Preferred Participating Provider levels as specified under Hospital Bene- fits Benefits (Facility Services), “Outpatient Services services for treatment of illness or inju- ryinjury, radiation therapy, chemotherapy and necessary supplies neces- sary supplies” in this Summary of Benefits and will be subject to any Calendar Year medical DeductibleBenefits. $100 per visit plus 3010% $100 per visit plus 3010% Emergency room Services Room services resulting in admission (billed as part of Inpa- tient inpatient Hospital Servicesservices) $250 100 per admission plus 3010% $250 100 per admission plus 3010% 11 Benefit Member Copayment 4 3 Services by Preferred, Participating, and Other Providers 5 4 Services by Non-Preferred Pre- ferred and Non-Participating Partici- pating Providers 6 5 Family Planning Benefits 12 7 Note: Copayments listed in this section are for Outpatient Physician Services outpatient Physi- cian services only. If Services services are performed at a facility (HospitalHospi- tal, Ambulatory Surgery Center, etc.), the facility Copayment listed under the appropriate applicable facility benefit in the Summary of Benefits will also apply, except for insertion and/or removal of intrauterine device (IUD), an intrauterine device (IUD), and tubal ligation. Counseling and consulting 1 (Including Physician office visits visit for diaphragm fitting fitting, injectable contraceptives or injectable contracep- tivesimplantable contraceptives.) 30% You pay nothing Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 30% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered Vasectomy 30% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Calen- dar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or oc- cupational therapist. 30% Not covered 13 Medical supplies 30% Not covered 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Services. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 30% Not covered 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Injectable Services Calendar Year visit limitation.) 30% Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 30% Not covered 14 General Inpatient care 30% Not covered 14 Inpatient Respite Care 1 You pay nothing Not covered 14 Pre-hospice consultation Implantable contraceptives 1 You pay nothing Not covered 14 Routine home care Injectable contraceptives 1 You pay nothing Not covered 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospital Benefits Insertion and/or removal of intrauterine device (Facility ServicesIUD) Inpatient Emergency Facility Services $250 per admission plus 30% $250 per admission plus 30% 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and supplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bar- iatric Surgery Benefits for Residents of Designated Counties in California sec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Services whether rendered in a Hospital or a free-standing Skilled Nursing Facility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 30% 50% Inpatient Services to treat acute medical complications of detoxification $250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical labor- atory services 30% 50% of up to $500 per day 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 30% 50% of up to $300 per day 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 $250 per surgery plus 30% 50% of up to $500 per day 15 Outpatient Services for treatment of illness or injury, radiation therapy, chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal deform- ity (Be sure to read the Principal Benefits and Coverages (Covered Services) sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 30% 50% of up to $300 per day Inpatient Hospital Services $250 per admission plus 30% 50% of up to $500 per day 15 Office location $45 per visit 50% Outpatient department of a Hospital $250 per surgery plus 30% 50% of up to $500 per day 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 16 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Pro- viders 18 Inpatient Mental Health Services Inpatient Hospital services $250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services You pay nothing 50Not covered Intrauterine device (IUD) 1 You pay nothing Not covered Tubal ligation 1 You pay nothing Not covered Vasectomy 10% Residential care for Mental Health Condition $250 per admission plus 30% 50% of up to $500 per day Non-Routine Outpatient Mental Health Services Behavioral Health Treatment in home or other non-institutional setting 30% 50% Behavioral Health Treatment in an office setting 30% 50% Electroconvulsive Therapy (ECT) 19 30% 50% Intensive Outpatient Program 19 30% 50% Partial Hospitalization Program 20 30% per episode 50% of up to $500 per day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 30% 50% Transcranial magnetic stimulation 30% 50% Routine Outpatient Mental Health Services Professional (Physician) office visits $45 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for orthot- ics Services. Office visits $45 per visit 50% Orthotic equipment and devices 30% 50% Benefit Member Copayment 4 Outpatient Prescription Drug Benefits 21, 22, 23 Participating Pharmacy 24 Non-Participating Pharmacy 25Not covered