Common use of Inpatient Services Clause in Contracts

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 Not Covered Retail clinics $20 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible $0 Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 Not Covered Retail clinics $20 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 020% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 020% - After deductible Not Covered Physician hospital visits 020% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible Not Covered In a hospital or other health care facility 020% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 020% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 20% - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 20% - After deductible Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 20% - After deductible Not Covered Retail clinics $20 20% - After deductible Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 20% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services 20% - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 After deductible Not Covered Organ transplant services 020% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 0% - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 0% - After deductible Not Covered Retail clinics $20 0% - After deductible Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 0% - After deductible Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 0% - After deductible Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 200% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% Standard $1,500 - After deductible Not Covered Enhanced $750 Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% Standard $1,500 - After deductible Not Covered Enhanced $750 Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% Not Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible $0 Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 40 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year Standard $0 30 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year Enhanced $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 15 Not Covered Retail clinics $20 30 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 15 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% $40 Not Covered Covered Benefits - After deductible Not CoveredSee Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Hospital based clinic visits $40 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 25 Not Covered Retail clinics $20 25 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 25 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 020% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 020% - After deductible Not Covered Physician hospital visits 020% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 020% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 020% - After deductible Not Covered Hospital based clinic visits $30 45 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 30 Not Covered PCP does not practice with PCMH model of care $20 40 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 30 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 40 Not Covered Retail clinics $20 45 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 40 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 020% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Hospital based clinic visits $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 Not Covered Retail clinics $20 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible $0 Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 50 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 30 Not Covered Retail clinics $20 30 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 50 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 30 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Hospital based clinic visits $50 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 30 Not Covered Retail clinics $20 30 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 50 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 30 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days unlimited days 0% - After deductible Not Covered Rehabilitation facility services* - Limited limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications, such as physical or occupational therapy. 0% Not Covered In a hospital or other health care facility facility. 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 0% - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 0% - After deductible Not Covered Retail clinics $20 0% - After deductible Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 0% - After deductible Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 0% - After deductible Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 200% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 Not Covered Retail clinics $20 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% $300 per admission - After deductible Afterdeductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% $300 per admission - After deductible Afterdeductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 40 - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 15 - After deductible Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 35 - After deductible Not Covered Retail clinics $20 40 - After deductible Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 40 - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services 35 - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 After deductible Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20$40 - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered Prescription drugs and diabetic equipment and supplies purchased at a retail, specialty, or mail order pharmacy. See Summary of PharmacyBenefits See Summary of Pharmacy Benefits Medical prescription drugs requiring administration by a licensed health care provider* : Medical prescription drugs other than infused drugs - includes but is not limited to: medications by injection or inhalation, as well as nasal, topical, or transdermal medications. 0% - After deductible Not Covered Infused drugs 0% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days days 0% - After deductible Deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Deductible Not Covered Physician hospital visits 0% - After deductible Deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - Diagnostic (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visitsvisit.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Deductible Not Covered Hospital based clinic visits $30 95 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - Primary Care Physicians (PCP) – including behavioral health. Visits include PCP office visits and visits, PCP house calls, and pediatric clinic visits. PCP practices with PCMH model of care • First 4 non-preventive visits rendered by a PCP in the plan year year. $0 50 Not Covered • Subsequent non-preventive visits rendered by a PCP in the plan year year. $10 50 - After Deductible Not Covered PCP does not practice with PCMH model of care • First 4 non-preventive visits rendered by a PCP in the plan year year. $0 70 Not Covered • Subsequent non-preventive visits rendered by a PCP in the plan year year. $20 70 - After Deductible Not Covered Retail clinics $20 50 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. $30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 95 Not Covered Organ transplant services 0% - After deductible Deductible Not Covered Outpatient hospital/in a physician’sdoctor’s/therapist’s office. 20office 0% - After deductible Deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible $0 Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 40 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 25 Not Covered Retail clinics $20 25 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 25 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 0% - After deductible Not Covered Retail clinics $20 0% - After deductible Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 0% - After deductible Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 0% - After deductible Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 200% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 020% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 020% - After deductible Not Covered Physician hospital visits 020% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 020% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 020% - After deductible Not Covered Hospital based clinic visits $30 45 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 20 Not Covered PCP does not practice with PCMH model of care $20 30 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 20 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 30 Not Covered Retail clinics $20 45 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 30 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 020% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 Not Covered Retail clinics $20 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered

Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% Standard $1,500 - After deductible Not Covered Enhanced $750 Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% Standard $1,500 - After deductible Not Covered Enhanced $750 Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Diabetic Office Visits Podiatrist Services - (Other than Preventive First routine visit in a plan year $0 Not Covered Vision Care ServicesServices - first routine eye exam in a plan year that includes a retinal eye exam. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible $0 Not Covered Hospital based clinic visits $30 Not Covered Pediatric clinic visit PCP practices with PCMH model of care $10 Not Covered PCP does not practice with PCMH model of care $20 40 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year Standard $0 30 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year Enhanced $10 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year $20 15 Not Covered Retail clinics $20 30 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 15 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible $40 Not Covered