Common use of Surgery Services Clause in Contracts

Surgery Services. Inpatient doctor services 20% - After Deductible 40% - After Deductible Outpatient doctor services 20% - After Deductible 40% - After Deductible In a doctor’s office 0% 40% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 20% - After Deductible 40% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 40% - After Deductible Lab and pathology services. 0% 40% - After Deductible 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.) 20% - After Deductible 40% - After Deductible Lyme disease-diagnosis 20% - After Deductible 40% - After Deductible Urgent Care Center Urgent care center/walk-in $50 $50 Vision Care Services Vision exam One routine eye exam per member per plan year. $40 40% - After Deductible BENEFIT BOOKLET Blue Cross & Blue Shield of Rhode Island TABLE OF CONTENTS SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4 1.0 INTRODUCTION 14

Surgery Services. Inpatient doctor services 200% - After Deductible 4020% - After Deductible Outpatient doctor services 200% - After Deductible 4020% - After Deductible In a doctor’s office 0% 4020% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 200% - After Deductible 4020% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 4020% - After Deductible Lab and pathology services. 0% 4020% - After Deductible 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.) 200% - After Deductible 4020% - After Deductible Lyme disease-diagnosis 0% - After Deductible 20% - After Deductible 40% - After Deductible Urgent Care Center Urgent care center/walk-in $50 $50 Vision Care Services Vision exam One routine eye exam per member per plan year. $40 40% - After Deductible BENEFIT BOOKLET Blue Cross & Blue Shield of Rhode Island TABLE OF CONTENTS SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4 1.0 INTRODUCTION 14Deductible

Surgery Services. Inpatient doctor services 200% - After Deductible 400% - After Deductible Outpatient doctor services 200% - After Deductible 400% - After Deductible In a doctor’s office 0% 40- After Deductible 0% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 0% - After Deductible Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 200% - After Deductible 400% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 40- After Deductible 0% - After Deductible Lab and pathology services. 0% 40- After Deductible 0% - After Deductible 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.) 200% - After Deductible 400% - After Deductible Lyme disease-diagnosis 200% - After Deductible 400% - After Deductible Urgent Care Center Urgent care center/walk-in $50 $50 Vision Care Services Vision exam One routine eye exam per member per plan year. $40 40% - After Deductible BENEFIT BOOKLET Blue Cross & Blue Shield of Rhode Island TABLE OF CONTENTS SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4 1.0 INTRODUCTION 14Deductible

Surgery Services. Inpatient doctor services 200% - After Deductible 4020% - After Deductible Outpatient doctor services 200% - After Deductible 4020% - After Deductible In a doctor’s office 0% 4020% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 30 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 200% - After Deductible 4020% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 4020% - After Deductible Lab and pathology services. 0% 4020% - After Deductible 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.) 200% - After Deductible 4020% - After Deductible Lyme disease-diagnosis 200% - After Deductible 4020% - After Deductible Urgent Care Center Urgent care center/walk-in $50 $50 Vision Care Services Vision exam One routine eye exam per member per plan year. $40 4050 20% - After Deductible BENEFIT BOOKLET Blue Cross & Blue Shield of Rhode Island TABLE OF CONTENTS SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4 1.0 INTRODUCTION 14