Common use of Pregnancy and Maternity Services Clause in Contracts

Pregnancy and Maternity Services. Pre-natal, deliverya,nd postpartum services. 0%- Afterdeductible 20%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), an notpurchased from a retail, specialty or mail order pharmacy: Injectable drugs* 0%- Afterdeductible 20%- Afterdeductible Infused drugs* 0%- Afterdeductible 20%- Afterdeductible Medications other than injected and infused rugs* Are included in thaellowance for the medical service bein rendered. Are included in thaellowance for the medical service being rendered. Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% 20%- Afterdeductible Must be performed by a certified home health care agen 0%- Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Inpatient 0%- Afterdeductible 20%- Afterdeductible Outpatient 0%- Afterdeductible 20%- Afterdeductible Skilled Care in a Nursing Facility* Skilled or su-bacute care 0%- Afterdeductible 20%- Afterdeductible Outpatient hospitainl/ a S K \ WV KL ▇▇ ▇▇ DD 20%- Afterdeductible 40%- Afterdeductible Inpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible Outpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0% 20%- Afterdeductible Telemedicine Services When rendered by a designatepdrovider. $25 Not Covered When rendered by anetworkprovider. $25 Not Covered Outpatien,tin a S K o\ ffiVce, uLrgenFt caLreceDnterQor ¶ free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans* nuclear medicine*. 0%- Afterdeductible 20%- Afterdeductible Sleep studies.* 0%- Afterdeductible 20%- Afterdeductible Diagnostic imaging and tests, other than the diagnosti imaging services listed above. $75 20%- Afterdeductible Lab and pathology services. $25 20%- Afterdeductible Diagnostic colorectal servic-e(sIncluding, but not limite to, fecal occult blodotesting, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0%- Afterdeductible 20%- Afterdeductible Lyme disease diagnosis and treatment $25 20%- Afterdeductibel Urgent care services $100 The level of coverage is the same as network ▇▇▇▇▇▇.▇▇ Vision Care Services Vision exam- one routine eye exam pemr emberper plan year. $0 20%- Afterdeductible Non-routine eye exam $0 20%- Afterdeductible Pediatric vision care fomrembersunder age 19: See Vision Services in Section 3 fobrenefitlimitsand details. These services only apply to an enrollmedemberunder the age of 19:. Prescription glasses- frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrollmedembersaged 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.

Pregnancy and Maternity Services. Pre-natal, deliverya,nd delivery, and postpartum services. 0%- Afterdeductible 20%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies 0% - After deductible 20% - After deductible Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacyorder pharmacy. See Summary of PharmacyBenefits See Summary of PharmacyBenefits Prescription drugs dispensed and administered requiring administration by a licensed health careprovider(other than a pharmacist), an notpurchased from a retail, specialty or mail order pharmacycare provider* : Injectable drugs* 0%- Afterdeductible 20%- Afterdeductible Infused drugs* 0%- Afterdeductible 20%- Afterdeductible Medications Prescription drugs other than injected and infused rugs* Are included in thaellowance for the medical service bein rendereddrugs - includes but is not limited to: medications by injection or inhalation, as well as nasal, topical, or transdermal medications. Are included in thaellowance for the medical service being rendered. 0% - After deductible 20% - After deductible Infused drugs 0% - After deductible 20% - After deductible Covered Benefits- Benefits - See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% 20%- Afterdeductible 20% - After deductible Must be performed by a certified home health care agen 0%- Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services agency. 0% - After deductible 20% - After deductible Outpatient 0%- Afterdeductible 20%- Afterdeductible 0% - After deductible 20% - After deductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Inpatient 0%- Afterdeductible 20%- Afterdeductible physician’s office 0% - After deductible 20% - After deductible Outpatient 0%- Afterdeductible 20%- Afterdeductible 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled Care or sub-acute care 0% - After deductible 20% - After deductible Outpatient hospital/in a Nursing Facility* Skilled physician’s/therapist’s office. 20% - After deductible 40% - After deductible Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or su-bacute care 0%- Afterdeductible 20%- Afterdeductible Outpatient hospitainl/ a S K \ WV KL ▇▇ ▇▇ DD 20%- Afterdeductible 40%- Afterdeductible Inpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible Outpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a S K o\ ffiVce L F L D Q ¶ V physician’s office 0% 20%- Afterdeductible Telemedicine Services 20% - After deductible When rendered by a designatepdroviderour designated telemedicine provider. $25 30 Not Covered When rendered by anetworkprovider. $25 Not Covered Outpatien,tin a S K o\ ffiVce, uLrgenFt caLreceDnterQor ¶ freenetwork provider or non-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans* nuclear medicine*. 0%- Afterdeductible 20%- Afterdeductible Sleep studies.* 0%- Afterdeductible 20%- Afterdeductible Diagnostic imaging and tests, network provider other than the diagnosti imaging services listed above. $75 20%- Afterdeductible Lab and pathology services. $25 20%- Afterdeductible Diagnostic colorectal servic-e(sIncluding, but not limite to, fecal occult blodotesting, flexible sigmoidoscopy, colonoscopy, and barium enemaour designated telemedicine provider. See Prevention and Early Detection Services the covered healthcare service being provided for preventive colorectal services.) 0%- Afterdeductible 20%- Afterdeductible Lyme disease diagnosis and treatment $25 20%- Afterdeductibel Urgent care services $100 The level of coverage is the same as network ▇▇▇▇▇▇.▇▇ Vision Care Services Vision exam- one routine eye exam pemr emberper plan year. $0 20%- Afterdeductible Non-routine eye exam $0 20%- Afterdeductible Pediatric vision care fomrembersunder age 19: amount you pay See Vision Services in Section 3 fobrenefitlimitsand details. These services only apply to an enrollmedemberunder the age of 19:. Prescription glasses- frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware covered healthcare service being provided for enrollmedembersaged 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.the amount you pay

Pregnancy and Maternity Services. Pre-natal, deliverya,nd delivery, and postpartum services. 0%- Afterdeductible 20%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies 0% - After deductible 20% - After deductible Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacyorder pharmacy. See Summary of PharmacyBenefits See Summary of PharmacyBenefits Prescription drugs dispensed and administered requiring administration by a licensed health careprovider(other than a pharmacist), an notpurchased from a retail, specialty or mail order pharmacycare provider*: Injectable drugs* 0%- Afterdeductible 20%- Afterdeductible Infused drugs* 0%- Afterdeductible 20%- Afterdeductible Medications Prescription drugs other than injected and infused rugs* Are included in thaellowance for the medical service bein rendereddrugs - includes but is not limited to: medications by injection or inhalation, as well as nasal, topical, or transdermal medications. Are included in thaellowance for the medical service being rendered. 0% - After deductible 20% - After deductible Infused drugs 0% - After deductible 20% - After deductible Covered Benefits- Benefits - See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% 20%- Afterdeductible 20% - After deductible Must be performed by a certified home health care agen 0%- Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services agency. 0% - After deductible 20% - After deductible Outpatient 0%- Afterdeductible 20%- Afterdeductible 0% - After deductible 20% - After deductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 20%- Afterdeductible physician’s office 0% - After deductible 20% - After deductible Inpatient 0%- Afterdeductible 20%- Afterdeductible 0% - After deductible 20% - After deductible Outpatient 0%- Afterdeductible 20%- Afterdeductible 0% - After deductible 20% - After deductible Skilled Care or sub-acute care 0% - After deductible 20% - After deductible Outpatient hospital/in a Nursing Facility* Skilled physician’s/therapist’s office. 20% - After deductible 40% - After deductible Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or su-bacute care 0%- Afterdeductible 20%- Afterdeductible Outpatient hospitainl/ a S K \ WV KL ▇▇ ▇▇ DD 20%- Afterdeductible 40%- Afterdeductible Inpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible Outpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a S K o\ ffiVce L F L D Q ¶ V physician’s office. 0% 20%- Afterdeductible Telemedicine Services 20% - After deductible When rendered by a designatepdroviderour designated telemedicine provider. $25 20 Not Covered When rendered by anetworkprovidera network provider or non-network provider other than our designated telemedicine provider. $25 Not Covered Outpatien,tin See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Outpatient, in a S K o\ ffiVcephysician’s office, uLrgenFt caLreceDnterQor ¶ 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*medicine and cardiac imaging. 0%- Afterdeductible 20%- Afterdeductible 0% - After deductible 20% - After deductible Sleep studies.* 0%- Afterdeductible 20%- Afterdeductible 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than the diagnosti major diagnostic imaging and testing services listed noted above. $75 20%- Afterdeductible 50 20% - After deductible Lab and pathology services. $25 20%- Afterdeductible 20 20% - After deductible Diagnostic colorectal servic-e(sIncludingservices - (Including, but not limite limited to, fecal occult blodotestingblood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0%- Afterdeductible 20%- Afterdeductible 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment $25 20%- Afterdeductibel 20 20% - After deductible Urgent care services $100 75 The level of coverage is the same as network ▇▇▇▇▇▇.▇▇ provider. Vision Care Services Vision exam- exam - one routine eye exam pemr emberper per member per plan year. $0 20%- Afterdeductible 20% - After deductible Non-routine eye exam $0 20%- Afterdeductible Pediatric vision care fomrembersunder age 19: See Vision Services in Section 3 fobrenefitlimitsand details. These services only apply to an enrollmedemberunder the age of 19:. Prescription glasses- frame and lenses 020% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrollmedembersaged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS - After deductible The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty. For information about our pharmacy network, pharmacyvisit our website or call our Customer Service Department.

Pregnancy and Maternity Services. Pre-natal, deliverya,nd delivery, and postpartum services. 0%- Afterdeductible 0% 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), an and notpurchased from a retail, specialty or mail order pharmacy: Injectable drugs* 0%- Afterdeductible drug*s 20% 20%- Afterdeductible Infused drugs* 0%- Afterdeductible drug*s 20% 20%- Afterdeductible Medications other than injected and infused rugs* d*rugs Are included in thaellowance the allowanc for the medical service bein rendered. Are included in thaellowance the allowanc for the medical service being rendered. See Prevention and Early Detection Services section fo details. 0% 20%- Afterdeductible Private Duty Nursing Service*s Must be performed by a certified home health care age 0% 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0% 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0% 20%- Afterdeductible Inpatient 0% 20%- Afterdeductible Outpatient 0% 20%- Afterdeductible Skilled or su-bacute care 0% 20%- Afterdeductible Outpatient hospitainl/ a S K \ WV KL ▇▇ ▇▇ DD Limited to30 speech therapy visits peprlan year. 20% 20%- Afterdeductible Inpatient physiciasnervices 0% 20%- Afterdeductible Outpatientservices - includesphysicianservices and outpatient hospitaolr ambulatory surgical centfearcility services. 0% 20%- Afterdeductible In a S K o\ ffiVce. L F L D Q ¶ V 0% 20%- Afterdeductible Telemedicine Services When rendered by a designatepdrovider. $15 Not Covered When rendered by anetworkprovider. $15 Not Covered Outpatien,tin a S K o\ ffiVce, uLrgenFt caLreceDnterQor ¶ free-standing laboratory: Major diagnostic imaging and tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans PET scans, nuclear medicine and cardiac imaging. 0% 20%- Afterdeductible Sleep studies*. 0% 20%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted abov 0% 20%- Afterdeductible Lab and pathology services. 0% 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% 20%- Afterdeductible Must be performed by a certified home health care agen 0%- Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Inpatient 0%- Afterdeductible 20%- Afterdeductible Outpatient 0%- Afterdeductible 20%- Afterdeductible Skilled Care in a Nursing Facility* Skilled or su-bacute care 0%- Afterdeductible 20%- Afterdeductible Outpatient hospitainl/ a S K \ WV KL ▇▇ ▇▇ DD 20%- Afterdeductible 40%- Afterdeductible Inpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible Outpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0% 20%- Afterdeductible Telemedicine Services When rendered by a designatepdrovider. $25 Not Covered When rendered by anetworkprovider. $25 Not Covered Outpatien,tin a S K o\ ffiVce, uLrgenFt caLreceDnterQor ¶ free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans* nuclear medicine*. 0%- Afterdeductible 20%- Afterdeductible Sleep studies.* 0%- Afterdeductible 20%- Afterdeductible Diagnostic imaging and tests, other than the diagnosti imaging services listed above. $75 20%- Afterdeductible Lab and pathology services. $25 20%- Afterdeductible Diagnostic colorectal servic-e(sIncluding, but not limite limited to, fecal occult blodotestingblood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See S Prevention and Early Detection Services for preventive colorectal services.) 0%- Afterdeductible 0% 20%- Afterdeductible Lyme disease diagnosis and treatment $25 0% 20%- Afterdeductibel Afterdeductible Urgent care services $100 15 The level of coverage is the same as network ▇▇▇▇▇▇.▇▇ Vision Care Services Vision exam- one routine eye exam pemr emberper plan year. $0 15 20%- Afterdeductible Non-routine eye routineeye exam $0 15 20%- Afterdeductible Pediatric vision care fomrembersunder age 19: See Vision Services in Section 3 fobrenefitlimitsand details. These services only apply to an enrollmedemberunder the age of 19:. Prescription glasses- frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrollmedembersaged 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.