SUMMARY OF MEDICAL BENEFITS. This is a summary of your medical benefit coverage levels under this agreement. It includes information about copayments, deductibles (if any), and some benefit limits. This summary is intended to give you a general understanding of the medical coverage available under this agreement. Please read Section 3.0 for a detailed description of coverage for each particular covered health care service, along with the related exclusions. Section 4.0 contains a list of general exclusions. Words or phrases in italics are defined in Section 8.0 - Glossary. IMPORTANT NOTE: All of our payments at the benefit levels noted below are based upon a fee schedule called our allowance. If you receive services from a network provider, the provider has agreed to accept our allowance as payment in full for covered health care services, excluding your copayments, deductible (if any), and the difference between the maximum benefit and our allowance, if any. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit, less any copayments and deductibles (if any), if any. The deductible (if any) and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated in this agreement. *Preauthorization is recommended for the services marked with an asterisk (*).Please see Section 1.6 – Preauthorization, Section 5.3 – Coverage for Services Provided Outside of the Service Area (BlueCard) and Section – 8.0 Glossary for more information. Deductible/Maximum out-of-pocket expense Benefit Description Description Benefit Limit/Notes Network Provider Non-Network Provider Deductible The deductible applies to both network and non-network services separately. Services that apply the deductible and services that do NOT apply the deductible are indicated in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Individual Plan Per benefit year $1,000 $2,000 Family Plan Per benefit year $2,000 The benefit year family deductible is met by adding the amount of covered health care expenses applied to the deductible for all family members; however no one (1) family member can contribute more than $1,000 towards the benefit year family deductible. $4,000 The benefit year family deductible is met by adding the amount of covered health care ex...

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SUMMARY OF MEDICAL BENEFITS. This is a summary of your medical benefits under this plan. It includes information about copayments, deductibles, and benefit limits. This summary is intended to give you a general understanding of the medical coverage available under this plan. Please read Section 3.0 for a detailed description of coverage for each covered healthcare service and Section 4.0

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SUMMARY OF MEDICAL BENEFITS. Your Plan: VantageBlue This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see: • Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy; • Covered Health Care Services - Section 3; • Health Care Services Not Covered Under This Agreement – Section 4; • Glossary – Section 8, for definitions of italicized words or phrases used throughout this agreement. *Preauthorization is recommended for services marked with an asterisk (*). Please see Preauthorization in Section 1 and Section 8 for more information.

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SUMMARY OF MEDICAL BENEFITS. Your Plan: BlueCHiP Flex This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see:  Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy;  Covered Health Care Services - Section 3;  Health Care Services Not Covered Under This Agreement – Section 4;  Glossary – Section 8, for definitions of italicized words or phrases used throughout this agreement. *Preauthorization is recommended for services marked with an asterisk (*). Please see Preauthorization in Section 1 and Section 8 for more information. COORDINATED CARE: Your primary care physician will coordinate your health care and refer you to other BlueCHiP providers when necessary. Only your primary care physician may refer you to other BlueCHiP providers. For example if your primary care physician refers you to a specialist, that specialist may not refer you to another specialist. In that case you would have to get a referral to the second specialist from your primary care physician. PERMITTED SELF-REFERRALS: You may self-refer to the following BlueCHiP providers for covered health care services:  Behavioral Health Services;  Chiropractors;  Early Intervention Services*;  Emergency Care (Emergency Room Services, Ambulance Services, and free-standing Emergency Medical Centers);  Hair Prosthetics (Wigs)*  Hearing Aids*  Obstetricians and Gynecologists;  Oncologists – Office Visits (consultation or second opinion; all other services require a referral);  Optometrists and Ophthalmologists;  Oral Surgery;  Pediatric Dental Services;  Retail Clinics; and  Telemedicine services (rendered by a designated provider. See Section 3.36 for details). * You may also self-refer to a non-network provider for covered health care services for Early Intervention Services, Hair Prosthetics, and Hearing Aids.

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SUMMARY OF MEDICAL BENEFITS. Please see the Tiered BlueHPN Markets section for copayment amounts and benefit limit information for covered healthcare services received from participating network providers in the Philadelphia and New Jersey BlueHPN Markets. 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 Ambulance Services Ground $50 The level of coverage is the same as network provider. Air/water* 0% - After deductible The level of coverage is the same as network provider.

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SUMMARY OF MEDICAL BENEFITS. This is a summary of your medical benefit coverage levels under this agreement. It includes information about copayments, deductibles, and some benefit limits. This summary is intended to give you a general understanding of the medical coverage available under this agreement. For more detailed information, please read Section 3.0 for the description of coverage for each particular covered health care service along with the related exclusions, and Section 4.0 for a list of general exclusions. Words or phrases used throughout this agreement that are in italics are defined in Section 8.0 - Glossary.

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SUMMARY OF MEDICAL BENEFITS. Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for thisservice. Please see Preauthorization in Section 5 for more information. You Pay You Pay Ambulance Services Ground $50 The level of coverage is the same as network xxxxxx.xx Air/wate*r $50 The level of coverage is the same as network xxxxxx.xx Autism Services Applied behavioral analysis Preauthorizationmay be required for services received fro a non-network xxxxxx.xx 0%- Afterdeductible Not Covered Physical/Occupational/Speech Therapy Servi-cAesutism Diagnosis- Outpatient Hospital 0%- Afterdeductible Not Covered Physical/Occupational/Speech Therapy Servi-cAesutism Diagnosis- In aprovider’soffice 0%- Afterdeductible Not Covered Behavioral Health Services M† ental Health and Substance Use Disorder Inpatient- Unlimited days at a generhaol spitalor a specialtyhospitalincluding detoxification or residential/rehabilitation ppelran year. Preauthorizationmay be required for services received fro a non-network provider. 0%- Afterdeductible Not Covered Outpatientor intermediate care servic*es- See Covered Healthcare Services: Behavioral Health Section for deta about partial hospital program, intensive outpatient prog adult intensive services, and child and family intensive treatment. Preauthorziationmay be required for services received fro a non-network provider. 0%- Afterdeductible Not Covered Office visit-sSee Office Visits section below for Behavio Health services provided byPaCP or specialist. Psychological Testing 0%- Afterdeductible Not Covered Medicatio-nassisted treatment- when rendered by a mental health or substance use disordeprrovide.r $30 Not Covered Methadone maintenance treatme-not ne copaymentper seven day period of treatment. $30 Not Covered Cardiac Rehabilitation Outpatient- Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0%- Afterdeductible Not Covered Chiropractic Services In aphysician’soffice- limited to 20 visits ppelran year. $50 Not Covered

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