Common use of Radiation Therapy/Chemotherapy Services Clause in Contracts

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our a 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 the amount you pay See the covered healthcare service being provided for the amount you pay0% - After deductible Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0Limited to 30 speech therapy visits per plan year. 20% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $25 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0Limited to 30 speech therapy visits per plan year. 20% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0Limited to 30 speech therapy visits per plan year. 20% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $25 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay$25 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $20 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. Limited to 30 speech therapy visits per plan year. 0% - After deductible 4020% - After deductible Surgery Services* Services Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office office. 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our a 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 the amount you pay See the covered healthcare service being provided for the amount you pay0% - After deductible Not Covered