Common use of Radiation Therapy/Chemotherapy Services Clause in Contracts

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. $45 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 Surgery Services* Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility. Standard $1,000 - After deductible Not Covered Enhanced $500 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 the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Respiratory Therapy Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. $45 10% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Surgery Services* Physician Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an and outpatient hospital or ambulatory surgical center facilityfacility services. Standard $1,000 10% - After deductible Not Covered Enhanced In a physician’s office $500 30 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 40 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Respiratory Therapy Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - 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 $45 30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Surgery Services* Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility. Standard $1,000 - After deductible Not Covered Enhanced $500 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 40 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Respiratory Therapy Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - 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 $45 20 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Surgery Services* Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility. Standard $1,000 - After deductible Not Covered Enhanced $500 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 35 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Respiratory Therapy Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. $45 10% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Surgery Services* Physician Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an and outpatient hospital or ambulatory surgical center facilityfacility services. Standard $1,000 10% - After deductible Not Covered Enhanced In a physician’s office $500 20 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 35 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. $45 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 Surgery Services* Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility. Standard $1,000 750 - After deductible Not Covered Enhanced $500 375 Not Covered Telemedicine Services When rendered by our a designated telemedicine provider. $20 15 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 $15 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Respiratory Therapy Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - 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 $45 30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Surgery Services* Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility. Standard $1,000 - After deductible Not Covered Enhanced $500 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 30 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. $45 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 Surgery Services* Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility. Standard $1,000 750 - After deductible Not Covered Enhanced $500 375 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 15 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible Not Covered In a physician’s office 020% - After deductible Not Covered Respiratory Therapy Inpatient 020% - After deductible Not Covered Outpatient 020% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. $45 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 Skilled Care in a Nursing Facility* Skilled or sub-acute care 20% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Surgery Services* Physician Inpatient physician services 20% - After deductible Not Covered Outpatient services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an and outpatient hospital or ambulatory surgical center facilityfacility services. Standard $1,000 20% - After deductible Not Covered Enhanced In a physician’s office $500 25 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 30 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 Not Covered