Common use of Well Child Care Clause in Contracts

Well Child Care. No Copayment Deductible & Coinsurance 7 exams from birth to 1 year 7 exams 1 through 5 years of age 1 exam every year from 5 through 11 years 1 exam every year from 11 through 22 years 1 exam every year 22+ Adult Physical Examinations No Copayment Deductible & Coinsurance Periodic, routine health examinations 1 exam every year 22+ Routine Gynecological Visit No Copayment Deductible & Coinsurance 1 visit per Calendar Year including pap smear Mammography No Charge Deductible & Coinsurance One baseline screening for female 35 through 39 years of age One screening mammogram every Calendar Year for female 40 and older Note: or more frequently if recommended by the woman’s Physician (M.D.) Vision Exams No Copayment Deductible & Coinsurance Calendar Year Hearing Exams No Copayment: Confirmed PPACA coverage. Additional exam cove age for those who don’t qualify for PPACA coverage Deductible & Coinsurance 1 hearing exam every 2 Calendar Years Immunizations and No Copayment Deductible & Coinsurance Vaccinations includes those needed for travel MEDICAL CARE Medical Office Visit Primary care office visits Specialist consultations OB/GYN care $20 Copayment Deductible & Coinsurance Maternity Care $20 Copayment Deductible & Coinsurance Initial visit subject to Copayment, no charge thereafter Allergy Office Visit/Testing No Copayment Deductible & Coinsurance Allergy Injections Immunotherapy or other therapy treatments No Copayment for Allergy Deductible & Coinsurance unlimited Injection Calendar Year period Diagnostic, Laboratory and X-ray No Charge Deductible & Coinsurance Services High Cost Diagnostic Tests No Charge Deductible & Coinsurance MRI, MRA, CAT, CTA, PET and SPECT scans HOSPITAL CARE – Prior authorization required All Inpatient Admissions Semi- private room Maternity and newborn care $200 Copayment Deductible & Coinsurance Copayment is waived if readmitted within 30 days for same diagnosis Skilled Nursing Facility No Copayment Deductible & Coinsurance up to 120 days per Calendar Year Specialty Hospital (Rehabilitation) No Copayment Deductible & Coinsurance 60 days per Covered Person per Calendar Year Outpatient Surgery No Copayment Deductible & Coinsurance In a licensed ambulatory surgical center (including colonoscopy) EMERGENCY CARE Walk-in centers $20 Copayment Deductible & Coinsurance Urgent care – at participating centers $20 Copayment Paid as an In-Network Service Emergency Room Treatment Emergency Room Copayment waived if the Covered Person is admitted directly to the Hospital from the emergency room $75 Copayment Paid as an In-Network Service Ambulance No Charge No Charge Land / Air Unlimited MENTAL HEALTH / SUBSTANCE ABUSE CARE Inpatient –unlimited $200 Copayment Deductible & Coinsurance Outpatient / office visits – unlimited – $20 Copayment Deductible & Coinsurance prior authorization after the 40th visit OTHER HEALTH CARE Outpatient Rehabilitation $20 Copayment Deductible & Coinsurance Outpatient rehabilitative and restorative physical, occupational, speech and chiropractic therapy unlimited Other Therapy Services: No Copayment Deductible & Coinsurance Outpatient cardiac rehabilitation therapy Radiation therapy: Chemotherapy for the treatment of cancer Electroshock Therapy Kidney Dialysis in a Hospital or free- standing dialysis center Private Duty Nursing No Copayment Deductible & Coinsurance limited to $15,000 Per Calendar Year Human Organ and Tissue Transplant No Copayment Deductible & Coinsurance Services Unlimited Home Health Care No Copayment Deductible* & 20% Coinsurance. Nursing and therapeutic services *After a $50 Deductible has been met, the Covered Person shall pay the applicable Coinsurance, plus amounts above the Maximum Allowable Amount. The Deductible for Home Health Care benefits accrues towards the Covered Person’s annual Deductible. limited to 200 visits Home health aide services unlimited $420 Medical Social Services for terminally ill – Subject to Treatment Plan Infusion Therapy No Copayment Deductible & Coinsurance Unlimited Durable Medical Equipment and No Cost Share Deductible & Coinsurance Prosthetic Devices Up to unlimited maximum per Covered Person per Calendar Year Hearing Aid Coverage available for all ages with no maximum Ostomy Related Services No Copayment Deductible & Coinsurance Wig No Copayment No Cost-Share No maximum Person per Calendar Year. Specialized Formula No Copayment Deductible & Coinsurance Hospice Care (inpatient) No Copayment Deductible & Coinsurance Covered within the last 6 months of life Infertility Services Please see Maternity/Family Planning Section of this document Office Visit $20 Copayment Deductible & Coinsurance Outpatient Hospital Same as Hospital Outpatient Inpatient Hospital Cost-Share Deductible & Coinsurance Infertility Drugs Same as Hospital Inpatient Cost- Share The maximum supply of a drug for Paid as Out-of-Network which benefits will be provided when dispensed under any one prescription is 30 day supply or 100 unit dose, whichever is greater Note: If this certificate has a Prescription Drug rider, see rider for infertility drug coverage. Infertility drugs will not apply to the Prescription Drug Rider Maximum. In the absence of a prescription drug rider then the coverage stated in this Schedule of Benefits will apply. PRESCRIPTION DRUGS

Well Child Care. No Copayment Deductible & Coinsurance 7 exams from birth to 1 year 7 exams 1 through 5 years of age 1 exam every year from 5 through 11 years 1 exam every year from 11 through 22 years 1 exam every year 22+ Adult Physical Examinations No Copayment Deductible & Coinsurance Adult Physical Examinations Periodic, routine health examinations 1 exam every year 22+ Routine Gynecological Visit No Copayment Deductible & Coinsurance Routine Gynecological Visit 1 visit per Calendar Year including pap smear Mammography No Charge Copayment Deductible & Coinsurance Mammography One baseline screening for female 35 through 39 years of age One screening mammogram every Calendar Year for female 40 and older Note: or more frequently if recommended by the woman’s Physician (M.D.) No Charge Deductible & Coinsurance Vision Exams 1 vision exam and refraction every Calendar Year No Copayment Deductible & Coinsurance Calendar Year Hearing Exams No Copayment: Confirmed PPACA coverage. Additional exam cove age for those who don’t qualify for PPACA coverage Deductible & Coinsurance 1 hearing exam every 2 Calendar Years Immunizations and No Copayment Deductible & Coinsurance Immunizations and Vaccinations includes those needed for travel No Copayment Deductible & Coinsurance APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION MEDICAL CARE Medical Office Visit Primary care office visits Specialist consultations OB/GYN care $20 Copayment Deductible & Coinsurance Maternity Care $20 Copayment Deductible & Coinsurance Initial visit subject to Copayment, no charge thereafter $20 Copayment Deductible & Coinsurance Allergy Office Visit/Testing No Copayment Deductible & Coinsurance Allergy Injections Immunotherapy or other therapy treatments Up to a maximum of 80 visits over a 3 Calendar Year period $20 Copayment No Copayment for Allergy Injection Deductible & Coinsurance unlimited Injection Calendar Year period Deductible & Coinsurance Diagnostic, Laboratory and X-ray Services No Charge Deductible & Coinsurance Services High Cost Diagnostic Tests No Charge Deductible & Coinsurance MRI, MRA, CAT, CTA, PET and SPECT scans No Charge Deductible & Coinsurance HOSPITAL CARE – Prior authorization required All Inpatient Admissions Semi- Semi-private room Maternity and newborn care $200 Copayment Deductible & Coinsurance Copayment is waived if readmitted within 30 days for same diagnosis Deductible & Coinsurance Skilled Nursing Facility No Copayment Deductible & Coinsurance up to 120 days per Calendar Year $200 Copayment Copayment is waived if admitted within 3 days of hospital discharge Deductible & Coinsurance Specialty Hospital (Rehabilitation) No Copayment Deductible & Coinsurance 60 days per Covered Person per Calendar Year Outpatient Surgery No $200 Copayment Deductible & Coinsurance Outpatient Surgery In a licensed ambulatory surgical center (including colonoscopy) No Copayment Deductible & Coinsurance EMERGENCY CARE Walk-in centers $20 Copayment Deductible & Coinsurance Urgent care – at participating centers $20 75 Copayment Paid as an In-Network Service Emergency Room Treatment Emergency Room Copayment waived if the Covered Person is admitted directly to the Hospital from the emergency room $75 Copayment Paid as an In-Network Service Ambulance Land / Air Unlimited No Charge No Charge Land / Air Unlimited APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION MENTAL HEALTH / SUBSTANCE ABUSE CARE Inpatient –unlimited $200 Copayment Deductible & Coinsurance Outpatient / office visits – unlimited – prior authorization after the 40th visit $20 Copayment Deductible & Coinsurance prior authorization after the 40th visit OTHER HEALTH CARE Outpatient Rehabilitation $20 Copayment Deductible & Coinsurance Outpatient rehabilitative and restorative physical, occupational, speech and chiropractic therapy unlimited for up to 50 combined visits per Calendar Year $20 Copayment Deductible & Coinsurance Other Therapy Services: No Copayment Deductible & Coinsurance Outpatient cardiac rehabilitation therapy Radiation therapy: Chemotherapy for the treatment of cancer Electroshock Therapy Kidney Dialysis in a Hospital or free- standing dialysis center Private Duty Nursing No Copayment Deductible & Coinsurance Private Duty Nursing limited to $15,000 Per Calendar Year Not Applicable Deductible & Coinsurance Human Organ and Tissue Transplant Services Unlimited No Copayment Deductible & Coinsurance Services Unlimited Home Health Care Nursing and therapeutic services limited to 200 visits Home health aide services limited to 80 visits that are applicable to the 200 visit limit $420 Medical Social Services for terminally ill – Subject to Treatment Plan No Copayment Deductible* & 20% Coinsurance. Nursing and therapeutic services Coinsurance *After a $50 Deductible has been met, the Covered Person shall pay the applicable Coinsurance, plus amounts above the Maximum Allowable Amount. The Deductible for Home Health Care benefits accrues towards the Covered Person’s annual Deductible. limited to 200 visits Home health aide services unlimited $420 Medical Social Services for terminally ill – Subject to Treatment Plan Infusion Therapy Unlimited No Copayment Deductible & Coinsurance Unlimited Durable Medical Equipment and No Cost Share Deductible & Coinsurance Prosthetic Devices Up to unlimited maximum per Covered Person per Calendar Year Hearing Aid Coverage available for all ages dependent children age 12 years and under with no a maximum of $1,000 within a two year period. No Cost Share Deductible & Coinsurance APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION Ostomy Related Services No Copayment Deductible & Coinsurance Wig Up to $350 maximum per Covered Person per Calendar Year. No Copayment No Cost-Share No maximum Person per Calendar Year. Specialized Formula No Copayment Deductible & Coinsurance Hospice Care (inpatient) No Copayment Deductible & Coinsurance Covered within the last 6 months of life No Copayment Deductible & Coinsurance Infertility Services Please see Maternity/Family Planning Section of this document Office Visit $20 Copayment Deductible & Coinsurance Outpatient Hospital Same as Hospital Outpatient Inpatient Hospital Cost-Share Deductible & Coinsurance Infertility Drugs Same as Hospital Inpatient Cost- Share The maximum supply of a drug for Paid as Out-of-Network which benefits will be provided when dispensed under any one on e prescription is 30 day supply or 100 unit dose, whichever is greater Note: If this certificate has a Prescription Drug rider, see rider for infertility drug coverage. Infertility drugs will not apply to the Prescription Drug Rider Maximum. In the absence of a prescription drug rider then the coverage stated in this Schedule of Benefits will apply. $20 Copayment Same as Hospital Outpatient Cost-Share Same as Hospital Inpatient Cost- Share Paid as Out-of-Network Deductible &Coinsurance Deductible &Coinsurance PRESCRIPTION DRUGS

Well Child Care. No Copayment Deductible & Coinsurance 7 exams from birth to 1 year 7 exams 1 through 5 years of age 1 exam every year from 5 through 11 years 1 exam every year from 11 through 22 years 1 exam every year 22+ Adult Physical Examinations No Copayment Deductible & Coinsurance Adult Physical Examinations Periodic, routine health examinations 1 exam every year 22+ Routine Gynecological Visit No Copayment Deductible & Coinsurance Routine Gynecological Visit 1 visit per Calendar Year including pap smear Mammography No Charge Copayment Deductible & Coinsurance Mammography One baseline screening for female 35 through 39 years of age One screening mammogram every Calendar Year for female 40 and older Note: or more frequently if recommended by the woman’s Physician (M.D.) No Charge Deductible & Coinsurance Vision Exams 1 vision exam and refraction every Calendar Year No Copayment Deductible & Coinsurance Calendar Year Hearing Exams No Copayment: Confirmed PPACA coverage. Additional exam cove age for those who don’t qualify for PPACA coverage Deductible & Coinsurance 1 hearing exam every 2 Calendar Years Immunizations and No Copayment Deductible & Coinsurance Immunizations and Vaccinations includes those needed for travel No Copayment Deductible & Coinsurance APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION MEDICAL CARE Medical Office Visit Primary care office visits Specialist consultations OB/GYN care $20 Copayment Deductible & Coinsurance Maternity Care $20 Copayment Deductible & Coinsurance Initial visit subject to Copayment, no charge thereafter $20 Copayment Deductible & Coinsurance Allergy Office Visit/Testing No Copayment Deductible & Coinsurance Allergy Injections Immunotherapy or other therapy treatments Up to a maximum of 80 visits over a 3 Calendar Year period $20 Copayment No Copayment for Allergy Injection Deductible & Coinsurance unlimited Injection Calendar Year period Deductible & Coinsurance Diagnostic, Laboratory and X-ray Services No Charge Deductible & Coinsurance Services High Cost Diagnostic Tests No Charge Deductible & Coinsurance MRI, MRA, CAT, CTA, PET and SPECT scans No Charge Deductible & Coinsurance HOSPITAL CARE – Prior authorization required All Inpatient Admissions Semi- Semi-private room Maternity and newborn care $200 Copayment Deductible & Coinsurance Copayment is waived if readmitted within 30 days for same diagnosis Deductible & Coinsurance Skilled Nursing Facility No Copayment Deductible & Coinsurance up to 120 days per Calendar Year $200 Copayment Copayment is waived if admitted within 3 days of hospital discharge Deductible & Coinsurance Specialty Hospital (Rehabilitation) No Copayment Deductible & Coinsurance 60 days per Covered Person per Calendar Year Outpatient Surgery No $200 Copayment Deductible & Coinsurance Outpatient Surgery In a licensed ambulatory surgical center (including colonoscopy) No Copayment Deductible & Coinsurance EMERGENCY CARE Walk-in centers $20 Copayment Deductible & Coinsurance Urgent care – at participating centers $20 75 Copayment Paid as an In-Network Service Emergency Room Treatment Emergency Room Copayment waived if the Covered Person is admitted directly to the Hospital from the emergency room $75 Copayment Paid as an In-Network Service Ambulance Land / Air Unlimited No Charge No Charge Land / Air Unlimited APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION MENTAL HEALTH / SUBSTANCE ABUSE CARE Inpatient –unlimited $200 Copayment Deductible & Coinsurance Outpatient / office visits – unlimited – prior authorization after the 40th visit $20 Copayment Deductible & Coinsurance prior authorization after the 40th visit OTHER HEALTH CARE Outpatient Rehabilitation $20 Copayment Deductible & Coinsurance Outpatient rehabilitative and restorative physical, occupational, speech and chiropractic therapy unlimited for up to 50 combined visits per Calendar Year $20 Copayment Deductible & Coinsurance Other Therapy Services: No Copayment Deductible & Coinsurance Outpatient cardiac rehabilitation therapy Radiation therapy: Chemotherapy for the treatment of cancer Electroshock Therapy Kidney Dialysis in a Hospital or free- standing dialysis center Private Duty Nursing No Copayment Deductible & Coinsurance Private Duty Nursing limited to $15,000 Per Calendar Year Not Applicable Deductible & Coinsurance Human Organ and Tissue Transplant Services Unlimited No Copayment Deductible & Coinsurance Services Unlimited Home Health Care Nursing and therapeutic services limited to 200 visits Home health aide services limited to 80 visits that are applicable to the 200 visit limit $420 Medical Social Services for terminally ill – Subject to Treatment Plan No Copayment Deductible* & 20% Coinsurance. Nursing and therapeutic services *After Coinsurance*After a $50 Deductible has been met, the Covered theCovered Person shall pay the applicable Coinsurance, plus amounts above the Maximum Allowable Amount. The Deductible for Home Health Care benefits accrues benefitsaccrues towards the Covered Person’s annual Deductible. limited to 200 visits Home health aide services unlimited $420 Medical Social Services for terminally ill – Subject to Treatment Plan Infusion Therapy Unlimited No Copayment Deductible & Coinsurance Unlimited Durable Medical Equipment and No Cost Share Deductible & Coinsurance Prosthetic Devices Up to unlimited maximum per Covered Person per Calendar Year Hearing Aid Coverage available for all ages dependent children age 12 years and under with no a maximum of $1,000 within a two year period. No Cost Share Deductible & Coinsurance APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION Ostomy Related Services No Copayment Deductible & Coinsurance Wig Up to $350 maximum per Covered Person per Calendar Year. No Copayment No Cost-Share No maximum Person per Calendar Year. Specialized Formula No Copayment Deductible & Coinsurance Hospice Care (inpatient) No Copayment Deductible & Coinsurance Covered within the last 6 months of life No Copayment Deductible & Coinsurance Infertility Services Please see Maternity/Family Planning Section of this document Office Visit $20 Copayment Deductible & Coinsurance Outpatient Hospital Same as Hospital Outpatient Inpatient Hospital Cost-Share Deductible & Coinsurance Infertility Drugs Same as Hospital Inpatient Cost- Share The maximum supply of a drug for Paid as Out-of-Network which benefits will be provided when dispensed under any one on e prescription is 30 day supply or 100 unit dose, whichever is greater Note: If this certificate has a Prescription Drug rider, see rider for infertility drug coverage. Infertility drugs will not apply to the Prescription Drug Rider Maximum. In the absence of a prescription drug rider then the coverage stated in this Schedule of Benefits will apply. $20 Copayment Same as Hospital Outpatient Cost-Share Same as Hospital Inpatient Cost- SharePaid as Out-of-Network Deductible & Coinsurance Deductible & Coinsurance PRESCRIPTION DRUGS

Well Child Care. No Copayment Deductible & Coinsurance 7 exams from birth to 1 year 7 exams 1 through 5 years of age 1 exam every year from 5 through 11 years 1 exam every year from 11 through 22 years 1 exam every year 22+ Adult Physical Examinations No Copayment Deductible & Coinsurance Adult Physical Examinations Periodic, routine health examinations 1 exam every year 22+ Routine Gynecological Visit No Copayment Deductible & Coinsurance Routine Gynecological Visit 1 visit per Calendar Year including pap smear Mammography No Charge Copayment Deductible & Coinsurance Mammography One baseline screening for female 35 through 39 years of age One screening mammogram every Calendar Year for female 40 and older Note: or more frequently if recommended by the woman’s Physician (M.D.) No Charge Deductible & Coinsurance Vision Exams 1 vision exam and refraction every Calendar Year No Copayment Deductible & Coinsurance Calendar Year Hearing Exams No Copayment: Confirmed PPACA coverage. Additional exam cove age for those who don’t qualify for PPACA coverage Deductible & Coinsurance 1 hearing exam every 2 Calendar Years Immunizations and No Copayment Deductible & Coinsurance Immunizations and Vaccinations includes those needed for travel No Copayment Deductible & Coinsurance APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION MEDICAL CARE Medical Office Visit Primary care office visits Specialist consultations OB/GYN care $20 Copayment Deductible & Coinsurance Maternity Care $20 Copayment Deductible & Coinsurance Initial visit subject to Copayment, no charge thereafter $20 Copayment Deductible & Coinsurance Allergy Office Visit/Testing No Copayment Deductible & Coinsurance Allergy Injections Immunotherapy or other therapy treatments Up to a maximum of 80 visits over a 3 Calendar Year period $20 Copayment No Copayment for Allergy Injection Deductible & Coinsurance unlimited Injection Calendar Year period Deductible & Coinsurance Diagnostic, Laboratory and X-ray Services No Charge Deductible & Coinsurance Services High Cost Diagnostic Tests No Charge Deductible & Coinsurance MRI, MRA, CAT, CTA, PET and SPECT scans No Charge Deductible & Coinsurance HOSPITAL CARE – Prior authorization required All Inpatient Admissions Semi- Semi-private room Maternity and newborn care $200 Copayment Deductible & Coinsurance Copayment is waived if readmitted within 30 days for same diagnosis Deductible & Coinsurance Skilled Nursing Facility No Copayment Deductible & Coinsurance up to 120 days per Calendar Year $200 Copayment Copayment is waived if admitted within 3 days of hospital discharge Deductible & Coinsurance Specialty Hospital (Rehabilitation) No Copayment Deductible & Coinsurance 60 days per Covered Person per Calendar Year Outpatient Surgery No $200 Copayment Deductible & Coinsurance Outpatient Surgery In a licensed ambulatory surgical center (including colonoscopy) No Copayment Deductible & Coinsurance EMERGENCY CARE Walk-in centers $20 Copayment Deductible & Coinsurance Urgent care – at participating centers $20 75 Copayment Paid as an In-Network Service Emergency Room Treatment Emergency Room Copayment waived if the Covered Person is admitted directly to the Hospital from the emergency room $75 Copayment Paid as an In-Network Service Ambulance Land / Air Unlimited No Charge No Charge Land / Air Unlimited APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION MENTAL HEALTH / SUBSTANCE ABUSE CARE Inpatient –unlimited $200 Copayment Deductible & Coinsurance Outpatient / office visits – unlimited – prior authorization after the 40th visit $20 Copayment Deductible & Coinsurance prior authorization after the 40th visit OTHER HEALTH CARE Outpatient Rehabilitation $20 Copayment Deductible & Coinsurance Outpatient rehabilitative and restorative physical, occupational, speech and chiropractic therapy unlimited for up to 50 combined visits per Calendar Year $20 Copayment Deductible & Coinsurance Other Therapy Services: No Copayment Deductible & Coinsurance Outpatient cardiac rehabilitation therapy Radiation therapy: Chemotherapy for the treatment of cancer Electroshock Therapy Kidney Dialysis in a Hospital or free- standing dialysis center Private Duty Nursing No Copayment Deductible & Coinsurance Private Duty Nursing limited to $15,000 Per Calendar Year Not Applicable Deductible & Coinsurance Human Organ and Tissue Transplant Services Unlimited No Copayment Deductible & Coinsurance Services Unlimited Home Health Care Nursing and therapeutic services limited to 200 visits Home health aide services limited to 80 visits that are applicable to the 200 visit limit $420 Medical Social Services for terminally ill – Subject to Treatment Plan No Copayment Deductible* & 20% Coinsurance. Nursing and therapeutic services *After a $50 Deductible has been met, the Covered Person shall pay the applicable Coinsurance, plus amounts above the Maximum Allowable Amount. The Deductible for Home Health Care benefits accrues towards the Covered Person’s annual Deductible. limited to 200 visits Home health aide services unlimited $420 Medical Social Services for terminally ill – Subject to Treatment Plan Infusion Therapy Unlimited No Copayment Deductible & Coinsurance Unlimited Durable Medical Equipment and No Cost Share Deductible & Coinsurance Prosthetic Devices Up to unlimited maximum per Covered Person per Calendar Year Hearing Aid Coverage available for all ages dependent children age 12 years and under with no a maximum of $1,000 within a two year period. No Cost Share Deductible & Coinsurance APPENDIX B BLOOMFIELD PPO BENEFIT PLAN DESCRIPTION Ostomy Related Services No Copayment Deductible & Coinsurance Wig Up to $350 maximum per Covered Person per Calendar Year. No Copayment No Cost-Share No maximum Person per Calendar Year. Specialized Formula No Copayment Deductible & Coinsurance Hospice Care (inpatient) No Copayment Deductible & Coinsurance Covered within the last 6 months of life No Copayment Deductible & Coinsurance Infertility Services Please see Maternity/Family Planning Section of this document Office Visit $20 Copayment Deductible & Coinsurance Outpatient Hospital Same as Hospital Outpatient Inpatient Hospital Cost-Share Deductible & Coinsurance Infertility Drugs Same as Hospital Inpatient Cost- Share The maximum supply of a drug for Paid as Out-of-Network which benefits will be provided when dispensed under any one prescription is 30 day supply or 100 unit dose, whichever is greater Note: If this certificate has a Prescription Drug rider, see rider for infertility drug coverage. Infertility drugs will not apply to the Prescription Drug Rider Maximum. In the absence of a prescription drug rider then the coverage stated in this Schedule of Benefits will apply. $20 Copayment Same as Hospital Outpatient Cost-Share Same as Hospital Inpatient Cost- Share Paid as Out-of-Network Deductible & Coinsurance Deductible & Coinsurance PRESCRIPTION DRUGS