Common use of Surgery Services Clause in Contracts

Surgery Services. Inpatient doctor services 0% - After Deductible 20% - After Deductible Outpatient doctor services 0% - After Deductible 20% - After Deductible In a doctor’s office 0% 20% - After Deductible See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Telemedicine services When rendered by a designated provider. $25 Not Covered 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.* 0% 20% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. 0% 20% - After Deductible Lab and pathology services. 0% 20% - 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.) 0% 20% - After Deductible Lyme disease-diagnosis 0% 20% - After Deductible Urgent care center/walk-in $50 20% plus $50 - After Deductible Vision exam One routine eye exam per member per plan year. $40 20% plus $40 - After Deductible 1.0 INTRODUCTION 13

Surgery Services. Inpatient doctor services 0% - After Deductible 20% - After Deductible Outpatient doctor services 0% - After Deductible 20% - After Deductible In a doctor’s office 0% 20% - After Deductible See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Telemedicine services When rendered by a designated provider. $25 30 Not Covered 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.* 0% - After Deductible 20% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 20% - After Deductible Lab and pathology services. 0% 20% - 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.) 0% - After Deductible 20% - After Deductible Lyme disease-diagnosis 0% - After Deductible 20% - After Deductible Urgent care center/walk-in $50 20% plus $50 - After Deductible Vision exam One routine eye exam per member per plan year. $40 50 20% plus $40 - After Deductible 1.0 INTRODUCTION 13SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4

Surgery Services. Inpatient doctor physician services 0% - After Deductible deductible 20% - After Deductible deductible Outpatient doctor physician services 0% - After Deductible deductible 20% - After Deductible deductible In a doctorphysician’s office 0% 20% - After Deductible See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Telemedicine services deductible When rendered by a designated provider. $25 15 Not Covered When rendered by a network provider. $15 Not Covered Outpatient/, in a doctorphysician’s office/, urgent care center or free- free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* and sleep medicine*. 0% 20% - After deductible Sleep studies.* 0% 20% - After Deductible deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. 0% 20% - After Deductible deductible Lab and pathology services. 0% 20% - After Deductible 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.) 0% 20% - After Deductible deductible Lyme disease-disease diagnosis and treatment 0% 20% - After Deductible deductible Urgent care center/walk-in services $50 25 20% plus $50 25 - After Deductible deductible Vision exam One - one routine eye exam per member per plan year. $40 25 20% plus $40 25 - After Deductible 1.0 INTRODUCTION 13deductible Non-routine eye exam $25 20% plus $25 - After deductible

Surgery Services. Inpatient doctor services 020% - After Deductible 2040% - After Deductible Outpatient doctor services 020% - After Deductible 2040% - After Deductible In a doctor’s office 0% 2040% - After Deductible See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Telemedicine services When rendered by a designated provider. $25 Not Covered 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.* 020% 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% 2040% - After Deductible Lab and pathology services. 0% 2040% - 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.) 020% 20- After Deductible 40% - After Deductible Lyme disease-diagnosis 020% 20- After Deductible 40% - After Deductible Urgent care center/walk-in $50 20% plus $50 - After Deductible Vision exam One routine eye exam per member per plan year. $40 2040% plus $40 - After Deductible 1.0 INTRODUCTION 13SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4