Common use of PharmacyBenefits See Summary of Pharmacy Benefits Clause in Contracts

PharmacyBenefits See Summary of Pharmacy Benefits. Medical prescription drugs requiringadministration 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. 10% - After deductible Not Covered Infused drugs 10% - After deductible Not Covered Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 10% - After deductible Not Covered Radiation Therapy/Chemotherapy Services Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Respiratory Therapy Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 10% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Surgery Services* Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay 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 Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 10% - After deductible Not Covered Sleep studies.* 10% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 10% - After deductible Not Covered Lab and pathology services. 10% - After deductible Not Covered Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 10% - After deductible Not Covered Lyme disease diagnosis and treatment 10% - After deductible Not Covered Urgent Care Urgent care services $75 - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $55 Not Covered Non-routine eye exam $45 Not Covered Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 10% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 10% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

PharmacyBenefits See Summary of Pharmacy Benefits. Medical prescription drugs requiringadministration 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. 10% - After deductible Not Covered Infused drugs 10% - After deductible Not Covered Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 10% - After deductible Not Covered Radiation Therapy/Chemotherapy Services Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Respiratory Therapy Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 10% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Surgery Services* Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 20 - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 25 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay 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 Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 10% - After deductible Not Covered Sleep studies.* 10% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 10% - After deductible Not Covered Lab and pathology services. 10% - After deductible Not Covered Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 10% - After deductible Not Covered Lyme disease diagnosis and treatment 10% - After deductible Not Covered Urgent Care Urgent care services $75 - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $55 40 Not Covered Non-routine eye exam $45 30 Not Covered Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 10% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 10% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

PharmacyBenefits See Summary of Pharmacy Benefits. Medical prescription drugs requiringadministration 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. 100% - After deductible Not Covered Infused drugs 100% - After deductible Not Covered Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 100% - After deductible Not Covered Radiation Therapy/Chemotherapy Services Outpatient 100% - After deductible Not Covered In a physician’s office 100% - After deductible Not Covered Respiratory Therapy Inpatient 100% - After deductible Not Covered Outpatient 100% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 10% $300 per admission - After deductible Afterdeductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 10% $40 - After deductible Not Covered Surgery Services* Inpatient physician services 100% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 100% - After deductible Not Covered In a physician’s office $30 0% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay 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 Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 10% $150 - After deductible Not Covered Sleep studies.* 10% $150 - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 100% - After deductible Not Covered Lab and pathology services. 100% - After deductible Not Covered Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 100% - After deductible Not Covered Lyme disease diagnosis and treatment 100% - After deductible Not Covered Urgent Care Urgent care services $75 - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $55 50 - After deductible Not Covered Non-routine eye exam $45 40- After deductible Not Covered Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 100% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 100% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.