Common use of Emergency Room Services Clause in Contracts

Emergency Room Services. Hospital emergency room 0% - After deductible The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 0% - After deductible Not Covered

Emergency Room Services. Hospital emergency room 010% - After deductible The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 010% - After deductible Not Covered Hearing diagnostic testing 010% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid. 2010% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 010% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 010% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 010% - After deductible Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 010% - After deductible Not Covered

Emergency Room Services. Hospital emergency room 0% - After deductible The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid. 200% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 0% - After deductible Not Covered