Common use of INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT Clause in Contracts

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 Gender Reassignment Services 32 Hearing Services 32 Home Health Care 32 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 SECTION 4: EXCLUSIONS 49 Air and Water Ambulance Services 49 Behavioral Health Services 49 Chiropractic Services 49 Dental Services 49 Dialysis Services 50 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 Experimental or Investigational Services 51 Gender Reassignment Services 51 Hearing Services 51 Home Health Care 51 Infertility Services 51 Inpatient Services 51 Organ Transplants 51 Pregnancy and Maternity Services 52 Prescription Drugs and Diabetic Equipment or Supplies 52 Private Duty Nursing Services 53 Surgery Services 53 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 Therapies 54 Vision Care Services 55 Providers 55 Services Available or Provided from Other Sources 55 All Other Exclusions 56 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 Requests for Authorization 59 Denials 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 How to File a Claim 67 How Network Providers Are Paid 67 How Non-network Providers Are Paid 68 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 Introduction 74 Definitions 74 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 When You Are Covered by More Than One Insurer 75 Our Right to Make Payments and Recover Overpayments 77 Our Right of Subrogation and/or Reimbursement 78 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 Behavioral HealthCare Parity 90 Genetic Information 90 Orally Administered Anticancer Medication 90 Our Right to Receive and Release Information About You 90 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 11 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 Physical/Occupational Therapy 36 35 Pregnancy and Maternity Services 36 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 50 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 53 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 54 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 61 60 Complaints 61 60 Reconsiderations and Appeals 62 61 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 66 How to File a Claim 67 66 How Network Providers Are Paid 67 66 How Non-network Providers Are Paid 68 67 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Our Right to Receive and Release Information About You 90 88 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 11 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 20 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 23 Dental Services 24 23 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 31 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 32 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 34 Physical/Occupational Therapy 36 35 Pregnancy and Maternity Services 36 35 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 50 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 53 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 54 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 61 60 Complaints 61 60 Reconsiderations and Appeals 62 61 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 66 How to File a Claim 67 66 How Network Providers Are Paid 67 66 How Non-network Providers Are Paid 68 67 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 73 Introduction 74 73 Definitions 74 73 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 74 When You Are Covered by More Than One Insurer 75 74 Our Right to Make Payments and Recover Overpayments 77 76 Our Right of Subrogation and/or Reimbursement 78 77 SECTION 8: GLOSSARY 80 79 SECTION 9: CONTACT INFORMATION 88 87 SECTION 10: NOTICES AND DISCLOSURES 90 89 Behavioral HealthCare Parity 90 89 Genetic Information 90 89 Orally Administered Anticancer Medication 90 89 Our Right to Receive and Release Information About You 90 89 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 90 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 25 Dental Services 24 25 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 32 Gender Reassignment Affirming Services 32 Hearing Services 32 33 Home Health Care 32 33 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 34 Inpatient Services 34 Mastectomy Services 34 35 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 36 Pediatric Neuropsychiatric Disorder Services 36 Physical/Occupational Therapy 36 37 Pregnancy and Maternity Services 36 37 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 44 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 SECTION 4: EXCLUSIONS 49 Air and Water Ambulance Services 49 Behavioral Health Services 49 Chiropractic Services 49 Dental Services 49 Dialysis Services 50 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 Experimental or Investigational Services 51 Gender Reassignment Affirming Services 51 Hearing Services 51 Home Health Care 51 Infertility Services 51 Inpatient Services 51 Organ Transplants 51 Pregnancy and Maternity Services 52 Prescription Drugs and Diabetic Equipment or Supplies 52 Private Duty Nursing Services 53 Surgery Services 53 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 Therapies 54 Vision Care Services 55 Providers 55 Services Available or Provided from Other Sources 55 All Other Exclusions 56 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 Requests for Authorization 59 Denials 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 How to File a Claim 67 How Network Providers Are Paid 67 How Non-network Providers Are Paid 68 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 70 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 Introduction 74 Definitions 74 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 When You Are Covered by More Than One Insurer 75 Our Right to Make Payments and Recover Overpayments 77 Our Right of Subrogation and/or Reimbursement 78 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 Behavioral HealthCare Health Care Parity 90 Genetic Information 90 Orally Administered Anticancer Medication 90 Our Right to Receive and Release Information About You 90 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 24 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 24 EARLY INTERVENTION SERVICES (EIS) 30 27 Education - Asthma 31 27 Emergency Room Services 31 27 Experimental or Investigational Services 31 28 Gender Reassignment Services 32 29 Hearing Services 32 29 Home Health Care 32 29 Hospice Care 33 29 Human Leukocyte Antigen Testing 33 29 Infertility Services 33 30 Infusion Therapy 33 30 Inpatient Services 34 30 Mastectomy Services 34 31 Observation Services 35 31 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 32 Organ Transplants 35 32 Physical/Occupational Therapy 36 33 Pregnancy and Maternity Services 36 33 Prescription Drugs 37 33 Preventive Care and Early Detection Services 41 37 Private Duty Nursing Services 43 39 Radiation Therapy/Chemotherapy Services 43 39 Respiratory Therapy 43 40 Skilled Care in a Nursing Facility 43 40 Speech Therapy 43 40 Surgery Services 44 40 Telemedicine Services 45 41 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 43 Vision Care Services 47 43 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 55 Requests for Authorization 59 55 Denials 61 57 Complaints 61 57 Reconsiderations and Appeals 62 58 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 70 Introduction 74 70 Definitions 74 70 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 71 When You Are Covered by More Than One Insurer 75 71 Our Right to Make Payments and Recover Overpayments 77 73 Our Right of Subrogation and/or Reimbursement 78 74 SECTION 8: GLOSSARY 80 76 SECTION 9: CONTACT INFORMATION 88 83 SECTION 10: NOTICES AND DISCLOSURES 90 85 Behavioral HealthCare Parity 90 85 Genetic Information 90 85 Orally Administered Anticancer Medication 90 85 Our Right to Receive and Release Information About You 90 85 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 86 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 Continuation of Coverage 17 Premiums and Grace Periods 19 SECTION 3: COVERED HEALTHCARE SERVICES 20 Acupuncture Services 21 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 30 Gender Affirming Services 31 Gender Reassignment Services 32 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 Pediatric Neuropsychiatric Disorder Services 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 45 SECTION 4: EXCLUSIONS 49 48 Acupuncture Services 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Affirming Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 60 Complaints 60 Appeals 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 65 How to File a Claim 67 65 How Network Providers Are Paid 67 65 How Non-network Providers Are Paid 68 66 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 68 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 73 Introduction 74 73 Definitions 74 73 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 74 When You Are Covered by More Than One Insurer 75 74 Our Right to Make Payments and Recover Overpayments 77 76 Our Right of Subrogation and/or Reimbursement 78 77 SECTION 8: GLOSSARY 80 79 SECTION 9: CONTACT INFORMATION 88 87 SECTION 10: NOTICES AND DISCLOSURES 90 89 Behavioral HealthCare Health Care Parity 90 89 Genetic Information 90 89 Orally Administered Anticancer Medication 90 89 Abortion Services 89 Our Right to Receive and Release Information About You 90 89 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 90 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 25 Dialysis Services 28 25 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 25 EARLY INTERVENTION SERVICES (EIS) 30 28 Education - Asthma 31 28 Emergency Room Services 31 28 Experimental or Investigational Services 31 29 Gender Reassignment Services 32 29 Hearing Services 32 30 Home Health Care 32 30 Hospice Care 33 30 Human Leukocyte Antigen Testing 33 30 Infertility Services 33 30 Infusion Therapy 33 31 Inpatient Services 34 31 Mastectomy Services 34 32 Observation Services 35 32 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 32 Organ Transplants 35 33 Physical/Occupational Therapy 36 33 Pregnancy and Maternity Services 36 34 Prescription Drugs 37 34 Preventive Care and Early Detection Services 41 38 Private Duty Nursing Services 43 40 Radiation Therapy/Chemotherapy Services 43 40 Respiratory Therapy 43 40 Skilled Care in a Nursing Facility 43 40 Speech Therapy 43 41 Surgery Services 44 41 Telemedicine Services 45 42 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 44 Vision Care Services 47 44 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 55 Requests for Authorization 59 55 Denials 61 57 Complaints 61 57 Reconsiderations and Appeals 62 58 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 70 Introduction 74 70 Definitions 74 70 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 71 When You Are Covered by More Than One Insurer 75 71 Our Right to Make Payments and Recover Overpayments 77 73 Our Right of Subrogation and/or Reimbursement 78 74 SECTION 8: GLOSSARY 80 76 SECTION 9: CONTACT INFORMATION 88 83 SECTION 10: NOTICES AND DISCLOSURES 90 85 Behavioral HealthCare Parity 90 85 Genetic Information 90 85 Orally Administered Anticancer Medication 90 85 Our Right to Receive and Release Information About You 90 85 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 86 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Acupuncture Services 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 25 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 Gender Reassignment Services 32 Hearing Services 32 Home Health Care 32 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 34 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 SECTION 4: EXCLUSIONS 49 Acupuncture Services 49 Air and Water Ambulance Services 49 Behavioral Health Services 49 Chiropractic Services 49 Dental Services 49 Dialysis Services 50 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 Experimental or Investigational Services 51 Gender Reassignment Services 51 Hearing Services 51 Home Health Care 51 Infertility Services 51 Inpatient Services 51 Organ Transplants 51 52 Pregnancy and Maternity Services 52 Prescription Drugs and Diabetic Equipment or Supplies 52 Private Duty Nursing Services 53 Surgery Services 53 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 Therapies 54 55 Vision Care Services 55 Providers 55 Services Available or Provided from Other Sources 55 56 All Other Exclusions 56 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 Requests for Authorization 59 Denials 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 How to File a Claim 67 How Network Providers Are Paid 67 How Non-network Providers Are Paid 68 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 Introduction 74 Definitions 74 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 When You Are Covered by More Than One Insurer 75 Our Right to Make Payments and Recover Overpayments 77 Our Right of Subrogation and/or Reimbursement 78 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 Behavioral HealthCare Parity 90 Genetic Information 90 Orally Administered Anticancer Medication 90 Our Right to Receive and Release Information About You 90 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 11 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 20 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 23 Dental Services 24 23 Dialysis Services 28 24 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 24 EARLY INTERVENTION SERVICES (EIS) 30 26 Education - Asthma 31 27 Emergency Room Services 31 27 Experimental or Investigational Services 31 27 Gender Reassignment Services 32 28 Hearing Services 32 28 Home Health Care 32 29 Hospice Care 33 29 Human Leukocyte Antigen Testing 33 29 Infertility Services 33 29 Infusion Therapy 33 30 Inpatient Services 34 30 Mastectomy Services 34 30 Observation Services 35 31 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 31 Organ Transplants 35 32 Physical/Occupational Therapy 36 32 Pregnancy and Maternity Services 36 33 Prescription Drugs 37 33 Preventive Care and Early Detection Services 41 37 Private Duty Nursing Services 43 39 Radiation Therapy/Chemotherapy Services 43 39 Respiratory Therapy 43 39 Skilled Care in a Nursing Facility 43 39 Speech Therapy 43 39 Surgery Services 44 40 Telemedicine Services 45 41 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 41 Urgent Care 46 42 Vision Care Services 47 43 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 55 Requests for Authorization 59 55 Denials 61 57 Complaints 61 57 Reconsiderations and Appeals 62 58 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 70 Introduction 74 70 Definitions 74 70 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 71 When You Are Covered by More Than One Insurer 75 71 Our Right to Make Payments and Recover Overpayments 77 73 Our Right of Subrogation and/or Reimbursement 78 74 SECTION 8: GLOSSARY 80 76 SECTION 9: CONTACT INFORMATION 88 84 SECTION 10: NOTICES AND DISCLOSURES 90 86 Behavioral HealthCare Parity 90 86 Genetic Information 90 86 Orally Administered Anticancer Medication 90 86 Our Right to Receive and Release Information About You 90 86 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 87 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 16 How to Add or Remove Coverage for Family Members 18 16 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 32 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 32 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 33 Organ Transplants 35 33 Physical/Occupational Therapy 36 34 Pregnancy and Maternity Services 36 34 Prescription Drugs 37 and Diabetic Equipment or Supplies 35 Preventive Care and Early Detection Services 41 38 Private Duty Nursing Services 43 40 Radiation Therapy/Chemotherapy Services 43 40 Respiratory Therapy 43 40 Skilled Care in a Nursing Facility 43 40 Speech Therapy 43 41 Surgery Services 44 41 Telemedicine Services 45 42 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 43 Vision Care Services 47 43 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 54 Requests for Authorization 59 54 Denials 61 56 Complaints 61 Reconsiderations and 56 Appeals 62 57 Legal Action 65 60 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 61 How to File a Claim 67 61 How Network Providers Are Paid 67 61 How Non-network Providers Are Paid 68 62 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Serviced Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 66 Introduction 74 66 Definitions 74 66 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 67 When You Are Covered by More Than One Insurer 75 67 Our Right to Make Payments and Recover Overpayments 77 69 Our Right of Subrogation and/or Reimbursement 78 70 SECTION 8: GLOSSARY 80 72 SECTION 9: CONTACT INFORMATION 88 80 SECTION 10: NOTICES AND DISCLOSURES 90 82 Behavioral HealthCare Parity 90 82 Genetic Information 90 82 Orally Administered Anticancer Medication 90 82 Our Right to Receive and Release Information About You 90 82 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 83 Mastectomy Services 84 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 25 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 25 EARLY INTERVENTION SERVICES (EIS) 30 27 Education - Asthma 31 28 Emergency Room Services 31 28 Experimental or Investigational Services 31 28 Gender Reassignment Affirming Services 32 29 Hearing Services 32 29 Home Health Care 32 29 Hospice Care 33 30 Human Leukocyte Antigen Testing 33 30 Infertility Services 33 30 Infusion Therapy 33 30 Inpatient Services 34 31 Mastectomy Services 34 31 Observation Services 35 32 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 32 Organ Transplants 35 32 Pediatric Neuropsychiatric Disorder Services 33 Physical/Occupational Therapy 36 33 Pregnancy and Maternity Services 36 34 Prescription Drugs 37 34 Preventive Care and Early Detection Services 41 38 Private Duty Nursing Services 43 40 Radiation Therapy/Chemotherapy Services 43 40 Respiratory Therapy 43 40 Skilled Care in a Nursing Facility 43 40 Speech Therapy 43 40 Surgery Services 44 41 Telemedicine Services 45 41 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 43 Vision Care Services 47 43 SECTION 4: EXCLUSIONS 49 44 Air and Water Ambulance Services 49 44 Behavioral Health Services 49 44 Chiropractic Services 49 44 Dental Services 49 44 Dialysis Services 50 45 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 45 Experimental or Investigational Services 51 46 Gender Reassignment Affirming Services 51 46 Hearing Services 51 46 Home Health Care 51 46 Infertility Services 51 46 Inpatient Services 51 46 Organ Transplants 51 46 Pregnancy and Maternity Services 52 47 Prescription Drugs and Diabetic Equipment or Supplies 52 47 Private Duty Nursing Services 53 48 Surgery Services 53 48 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 49 Therapies 54 49 Vision Care Services 55 50 Providers 55 50 Services Available or Provided from Other Sources 55 50 All Other Exclusions 56 51 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 54 Requests for Authorization 59 54 Denials 61 56 Complaints 61 56 Reconsiderations and Appeals 62 57 Legal Action 65 60 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 62 How to File a Claim 67 62 How Network Providers Are Paid 67 62 How Non-network Providers Are Paid 68 63 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 65 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 70 Introduction 74 70 Definitions 74 70 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 71 When You Are Covered by More Than One Insurer 75 71 Our Right to Make Payments and Recover Overpayments 77 73 Our Right of Subrogation and/or Reimbursement 78 74 SECTION 8: GLOSSARY 80 76 SECTION 9: CONTACT INFORMATION 88 83 SECTION 10: NOTICES AND DISCLOSURES 90 85 Behavioral HealthCare Parity 90 85 Genetic Information 90 85 Orally Administered Anticancer Medication 90 85 Our Right to Receive and Release Information About You 90 85 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 86 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 31 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 34 Physical/Occupational Therapy 36 35 Pregnancy and Maternity Services 36 35 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 50 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 53 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 54 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 61 60 Complaints 61 60 Reconsiderations and Appeals 62 61 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 66 How to File a Claim 67 66 How Network Providers Are Paid 67 66 How Non-network Providers Are Paid 68 67 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 69 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 73 Introduction 74 73 Definitions 74 73 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 74 When You Are Covered by More Than One Insurer 75 74 Our Right to Make Payments and Recover Overpayments 77 76 Our Right of Subrogation and/or Reimbursement 78 77 SECTION 8: GLOSSARY 80 79 SECTION 9: CONTACT INFORMATION 88 87 SECTION 10: NOTICES AND DISCLOSURES 90 89 Behavioral HealthCare Parity 90 89 Genetic Information 90 89 Orally Administered Anticancer Medication 90 89 Our Right to Receive and Release Information About You 90 89 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 90 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 11 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 Continuation of Coverage 17 Premiums and Grace Periods 19 SECTION 3: COVERED HEALTHCARE SERVICES 20 Acupuncture Services 21 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 30 Gender Affirming Services 31 Gender Reassignment Services 32 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 Pediatric Neuropsychiatric Disorder Services 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 45 SECTION 4: EXCLUSIONS 49 48 Acupuncture Services 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Affirming Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 60 Complaints 60 Appeals 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 65 How to File a Claim 67 65 How Network Providers Are Paid 67 65 How Non-network Providers Are Paid 68 66 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 68 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Health Care Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Abortion Services 88 Our Right to Receive and Release Information About You 90 88 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 Physical/Occupational Therapy 36 35 Pregnancy and Maternity Services 36 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 45 SECTION 4: EXCLUSIONS 49 47 Air and Water Ambulance Services 49 47 Behavioral Health Services 49 47 Chiropractic Services 49 47 Dental Services 49 47 Dialysis Services 50 48 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 48 Experimental or Investigational Services 51 49 Gender Reassignment Services 51 49 Hearing Services 51 49 Home Health Care 51 49 Infertility Services 51 49 Inpatient Services 51 49 Organ Transplants 51 49 Pregnancy and Maternity Services 52 50 Prescription Drugs and Diabetic Equipment or Supplies 52 50 Private Duty Nursing Services 53 51 Surgery Services 53 51 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 52 Therapies 54 52 Vision Care Services 55 53 Providers 55 53 Services Available or Provided from Other Sources 55 53 All Other Exclusions 56 54 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 57 Requests for Authorization 57 Denials 59 Denials 61 Complaints 61 59 Reconsiderations and Appeals 62 60 Legal Action 65 63 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 65 How to File a Claim 67 65 How Network Providers Are Paid 67 65 How Non-network Providers Are Paid 68 66 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 67 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Our Right to Receive and Release Information About You 90 88 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 14 How to Use This Agreement 11 14 Contact Us If You Have a Question 11 14 Your Member Identification Card 12 15 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 15 Programs to Keep You Healthy 12 16 About This Agreement 14 17 SECTION 2: ELIGIBILITY 15 19 Who Is an Eligible Person 15 19 When Your Coverage Begins 16 20 Coverage for Members Who Are Hospitalized on Their Effective Date 18 22 How to Add or Remove Coverage for Family Members 18 22 When Your Coverage Ends 18 22 Continuation of Coverage 19 23 SECTION 3: COVERED HEALTHCARE SERVICES 21 25 Ambulance Services 21 26 Autism Services 22 26 Behavioral Health Services 23 27 Cardiac Rehabilitation 24 29 Chiropractic Services 24 29 Dental Services 24 29 Dialysis Services 28 32 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 32 EARLY INTERVENTION SERVICES (EIS) 30 34 Education - Asthma 31 35 Emergency Room Services 31 35 Experimental or Investigational Services 31 35 Gender Reassignment Services 32 36 Hearing Services 32 36 Home Health Care 32 36 Hospice Care 33 37 Human Leukocyte Antigen Testing 33 37 Infertility Services 33 37 Infusion Therapy 33 38 Inpatient Services 34 38 Mastectomy Services 34 38 Observation Services 35 39 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 39 Organ Transplants 35 39 Physical/Occupational Therapy 36 40 Pregnancy and Maternity Services 36 40 Prescription Drugs 37 and Diabetic Equipment or Supplies 41 Preventive Care and Early Detection Services 41 44 Private Duty Nursing Services 43 46 Radiation Therapy/Chemotherapy Services 43 46 Respiratory Therapy 43 46 Skilled Care in a Nursing Facility 43 47 Speech Therapy 43 47 Surgery Services 44 47 Telemedicine Services 45 48 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 48 Urgent Care 46 49 Vision Care Services 47 50 SECTION 4: EXCLUSIONS 49 52 Air and Water Ambulance Services 49 52 Behavioral Health Services 49 52 Chiropractic Services 49 52 Dental Services 49 52 Dialysis Services 50 53 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 53 Experimental or Investigational Services 51 54 Gender Reassignment Services 51 54 Hearing Services 51 54 Home Health Care 51 54 Infertility Services 51 54 Inpatient Services 51 54 Organ Transplants 51 54 Pregnancy and Maternity Services 52 54 Prescription Drugs and Diabetic Equipment or Supplies 52 55 Private Duty Nursing Services 53 56 Surgery Services 53 56 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 57 Therapies 54 57 Vision Care Services 55 58 Providers 55 58 Services Available or Provided from Other Sources 55 58 All Other Exclusions 56 59 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 62 Requests for Authorization 59 62 Denials 61 64 Complaints 61 64 Reconsiderations and Appeals 62 65 Legal Action 65 68 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 70 How to File a Claim 67 70 How Network Providers Are Paid 67 70 How Non-network Providers Are Paid 68 71 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 72 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 76 Introduction 74 76 Definitions 74 76 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 77 When You Are Covered by More Than One Insurer 75 77 Our Right to Make Payments and Recover Overpayments 77 79 Our Right of Subrogation and/or Reimbursement 78 80 SECTION 8: GLOSSARY 80 82 SECTION 9: CONTACT INFORMATION 88 90 SECTION 10: NOTICES AND DISCLOSURES 90 92 Behavioral HealthCare Parity 90 92 Genetic Information 90 92 Orally Administered Anticancer Medication 90 92 Our Right to Receive and Release Information About You 90 92 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 93 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 11 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 20 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 23 Dental Services 24 23 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 31 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 32 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 34 Physical/Occupational Therapy 36 35 Pregnancy and Maternity Services 36 35 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 50 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 53 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 54 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 61 60 Complaints 61 60 Reconsiderations and Appeals 62 61 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 66 How to File a Claim 67 66 How Network Providers Are Paid 67 66 How Non-network Providers Are Paid 68 67 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 69 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 73 Introduction 74 73 Definitions 74 73 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 74 When You Are Covered by More Than One Insurer 75 74 Our Right to Make Payments and Recover Overpayments 77 76 Our Right of Subrogation and/or Reimbursement 78 77 SECTION 8: GLOSSARY 80 79 SECTION 9: CONTACT INFORMATION 88 87 SECTION 10: NOTICES AND DISCLOSURES 90 89 Behavioral HealthCare Parity 90 89 Genetic Information 90 89 Orally Administered Anticancer Medication 90 89 Our Right to Receive and Release Information About You 90 89 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 90 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 24 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 24 EARLY INTERVENTION SERVICES (EIS) 30 27 Education - Asthma 31 27 Emergency Room Services 31 27 Experimental or Investigational Services 31 28 Gender Reassignment Services 32 29 Hearing Services 32 29 Home Health Care 32 29 Hospice Care 33 29 Human Leukocyte Antigen Testing 33 29 Infertility Services 33 30 Infusion Therapy 33 30 Inpatient Services 34 30 Mastectomy Services 34 31 Observation Services 35 31 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 32 Organ Transplants 35 32 Physical/Occupational Therapy 36 33 Pregnancy and Maternity Services 36 33 Prescription Drugs 37 33 Preventive Care and Early Detection Services 41 37 Private Duty Nursing Services 43 39 Radiation Therapy/Chemotherapy Services 43 39 Respiratory Therapy 43 39 Skilled Care in a Nursing Facility 43 39 Speech Therapy 43 40 Surgery Services 44 40 Telemedicine Services 45 41 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 41 Urgent Care 46 43 Vision Care Services 47 43 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 47 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 48 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 54 Requests for Authorization 59 54 Denials 61 56 Complaints 61 56 Reconsiderations and Appeals 62 57 Legal Action 65 60 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 62 How to File a Claim 67 62 How Network Providers Are Paid 67 62 How Non-network Providers Are Paid 68 63 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 68 Introduction 74 68 Definitions 74 68 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 69 When You Are Covered by More Than One Insurer 75 69 Our Right to Make Payments and Recover Overpayments 77 71 Our Right of Subrogation and/or Reimbursement 78 72 SECTION 8: GLOSSARY 80 74 SECTION 9: CONTACT INFORMATION 88 81 SECTION 10: NOTICES AND DISCLOSURES 90 83 Behavioral HealthCare Parity 90 83 Genetic Information 90 83 Orally Administered Anticancer Medication 90 83 Our Right to Receive and Release Information About You 90 83 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 84 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 24 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 24 EARLY INTERVENTION SERVICES (EIS) 30 27 Education - Asthma 31 27 Emergency Room Services 31 27 Experimental or Investigational Services 31 28 Gender Reassignment Services 32 29 Hearing Services 32 29 Home Health Care 32 29 Hospice Care 33 29 Human Leukocyte Antigen Testing 33 29 Infertility Services 33 30 Infusion Therapy 33 30 Inpatient Services 34 30 Mastectomy Services 34 31 Observation Services 35 31 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 32 Organ Transplants 35 32 Physical/Occupational Therapy 36 33 Pregnancy and Maternity Services 36 33 Prescription Drugs 37 33 Preventive Care and Early Detection Services 41 37 Private Duty Nursing Services 43 39 Radiation Therapy/Chemotherapy Services 43 39 Respiratory Therapy 43 40 Skilled Care in a Nursing Facility 43 40 Speech Therapy 43 40 Surgery Services 44 40 Telemedicine Services 45 41 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 43 Vision Care Services 47 43 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 55 Requests for Authorization 59 55 Denials 61 57 Complaints 61 57 Reconsiderations and Appeals 62 58 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 70 Introduction 74 70 Definitions 74 70 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 71 When You Are Covered by More Than One Insurer 75 71 Our Right to Make Payments and Recover Overpayments 77 73 Our Right of Subrogation and/or Reimbursement 78 74 SECTION 8: GLOSSARY 80 76 SECTION 9: CONTACT INFORMATION 88 84 SECTION 10: NOTICES AND DISCLOSURES 90 86 Behavioral HealthCare Parity 90 86 Genetic Information 90 86 Orally Administered Anticancer Medication 90 86 Our Right to Receive and Release Information About You 90 86 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 87 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 24 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 24 EARLY INTERVENTION SERVICES (EIS) 30 27 Education - Asthma 31 27 Emergency Room Services 31 27 Experimental or Investigational Services 31 28 Gender Reassignment Services 32 28 Hearing Services 32 29 Home Health Care 32 29 Hospice Care 33 29 Human Leukocyte Antigen Testing 33 29 Infertility Services 33 29 Infusion Therapy 33 30 Inpatient Services 34 30 Mastectomy Services 34 Observation Services 35 31 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 31 Organ Transplants 35 32 Physical/Occupational Therapy 36 32 Pregnancy and Maternity Services 36 33 Prescription Drugs 37 and Diabetic Equipment or Supplies 33 Preventive Care and Early Detection Services 41 37 Private Duty Nursing Services 43 38 Radiation Therapy/Chemotherapy Services 43 39 Respiratory Therapy 43 39 Skilled Care in a Nursing Facility 43 39 Speech Therapy 43 39 Surgery Services 44 39 Telemedicine Services 45 40 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 40 Urgent Care 46 42 Vision Care Services 47 42 SECTION 4: EXCLUSIONS 49 44 Air and Water Ambulance Services 49 44 Behavioral Health Services 49 44 Chiropractic Services 49 44 Dental Services 49 44 Dialysis Services 50 45 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 45 Experimental or Investigational Services 51 46 Gender Reassignment Services 51 46 Hearing Services 51 46 Home Health Care 51 46 Infertility Services 51 46 Inpatient Services 51 46 Organ Transplants 51 46 Pregnancy and Maternity Services 52 47 Prescription Drugs and Diabetic Equipment or Supplies 52 47 Private Duty Nursing Services 53 48 Surgery Services 53 48 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 49 Therapies 54 49 Vision Care Services 55 50 Providers 55 50 Services Available or Provided from Other Sources 55 50 All Other Exclusions 56 51 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 53 Requests for Authorization 59 53 Denials 61 55 Complaints 61 55 Reconsiderations and Appeals 62 56 Legal Action 65 59 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 61 How to File a Claim 67 61 How Network Providers Are Paid 67 61 How Non-network Providers Are Paid 68 62 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 63 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 66 Introduction 74 66 Definitions 74 66 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 67 When You Are Covered by More Than One Insurer 75 67 Our Right to Make Payments and Recover Overpayments 77 69 Our Right of Subrogation and/or Reimbursement 78 70 SECTION 8: GLOSSARY 80 72 SECTION 9: CONTACT INFORMATION 88 80 SECTION 10: NOTICES AND DISCLOSURES 90 82 Behavioral HealthCare Parity 90 82 Genetic Information 90 82 Orally Administered Anticancer Medication 90 82 Our Right to Receive and Release Information About You 90 82 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 83 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 11 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 Continuation of Coverage 17 Premiums and Grace Periods 19 SECTION 3: COVERED HEALTHCARE SERVICES 20 Acupuncture Services 21 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 30 Gender Affirming Services 31 Gender Reassignment Services 32 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 Pediatric Neuropsychiatric Disorder Services 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Acupuncture Services 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Affirming Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 60 Complaints 60 Appeals 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 65 How to File a Claim 67 65 How Network Providers Are Paid 67 65 How Non-network Providers Are Paid 68 66 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 68 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Health Care Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Our Right to Receive and Release Information About You 90 88 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 16 How to Add or Remove Coverage for Family Members 18 16 When Your Coverage Ends 17 Premiums and Grace Periods 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Acupuncture Services 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 32 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 33 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 33 Organ Transplants 35 34 Physical/Occupational Therapy 36 34 Pregnancy and Maternity Services 36 35 Prescription Drugs 37 and Diabetic Equipment or Supplies 35 Preventive Care and Early Detection Services 41 39 Private Duty Nursing Services 43 40 Radiation Therapy/Chemotherapy Services 43 41 Respiratory Therapy 43 41 Skilled Care in a Nursing Facility 43 41 Speech Therapy 43 41 Surgery Services 44 41 Telemedicine Services 45 42 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 43 Vision Care Services 47 44 SECTION 4: EXCLUSIONS 49 46 Acupuncture Services 46 Air and Water Ambulance Services 49 Behavioral Health Services 49 46 Chiropractic Services 49 46 Dental Services 49 47 Dialysis Services 50 47 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 47 Experimental or Investigational Services 51 48 Gender Reassignment Services 51 48 Hearing Services 51 48 Home Health Care 51 48 Infertility Services 51 48 Inpatient Services 51 48 Organ Transplants 51 49 Pregnancy and Maternity Services 52 49 Prescription Drugs and Diabetic Equipment or Supplies 52 49 Private Duty Nursing Services 53 50 Surgery Services 53 50 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 51 Therapies 54 52 Vision Care Services 55 52 Providers 55 52 Services Available or Provided from Other Sources 55 53 All Other Exclusions 56 53 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 56 Requests for Authorization 56 Denials 58 Complaints 58 Appeals 59 Denials 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Serviced Area 65 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 69 Introduction 74 69 Definitions 74 69 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 70 When You Are Covered by More Than One Insurer 75 70 Our Right to Make Payments and Recover Overpayments 77 72 Our Right of Subrogation and/or Reimbursement 78 73 SECTION 8: GLOSSARY 80 75 SECTION 9: CONTACT INFORMATION 88 83 SECTION 10: NOTICES AND DISCLOSURES 90 85 Behavioral HealthCare Parity 90 85 Genetic Information 90 85 Orally Administered Anticancer Medication 90 85 Our Right to Receive and Release Information About You 90 85 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 86 Mastectomy Services 87 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 20 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 24 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 24 EARLY INTERVENTION SERVICES (EIS) 30 27 Education - Asthma 31 27 Emergency Room Services 31 27 Experimental or Investigational Services 31 28 Gender Reassignment Services 32 28 Hearing Services 32 29 Home Health Care 32 29 Hospice Care 33 29 Human Leukocyte Antigen Testing 33 29 Infertility Services 33 29 Infusion Therapy 33 30 Inpatient Services 34 30 Mastectomy Services 34 Observation Services 35 31 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 31 Organ Transplants 35 32 Physical/Occupational Therapy 36 32 Pregnancy and Maternity Services 36 33 Prescription Drugs 37 and Diabetic Equipment or Supplies 33 Preventive Care and Early Detection Services 41 37 Private Duty Nursing Services 43 38 Radiation Therapy/Chemotherapy Services 43 39 Respiratory Therapy 43 39 Skilled Care in a Nursing Facility 43 39 Speech Therapy 43 39 Surgery Services 44 39 Telemedicine Services 45 40 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 41 Urgent Care 46 42 Vision Care Services 47 42 SECTION 4: EXCLUSIONS 49 43 Air and Water Ambulance Services 49 43 Behavioral Health Services 49 43 Chiropractic Services 49 43 Dental Services 49 43 Dialysis Services 50 44 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 44 Experimental or Investigational Services 51 45 Gender Reassignment Services 51 45 Hearing Services 51 45 Home Health Care 51 45 Infertility Services 51 45 Inpatient Services 51 45 Organ Transplants 51 45 Pregnancy and Maternity Services 52 46 Prescription Drugs and Diabetic Equipment or Supplies 52 46 Private Duty Nursing Services 53 47 Surgery Services 53 47 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 48 Therapies 54 48 Vision Care Services 55 49 Providers 55 49 Services Available or Provided from Other Sources 55 49 All Other Exclusions 56 50 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 52 Requests for Authorization 59 52 Denials 61 54 Complaints 61 54 Reconsiderations and Appeals 62 55 Legal Action 65 58 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 60 How to File a Claim 67 60 How Network Providers Are Paid 67 60 How Non-network Providers Are Paid 68 61 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 65 Introduction 74 65 Definitions 74 65 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 66 When You Are Covered by More Than One Insurer 75 66 Our Right to Make Payments and Recover Overpayments 77 68 Our Right of Subrogation and/or Reimbursement 78 69 SECTION 8: GLOSSARY 80 71 SECTION 9: CONTACT INFORMATION 88 79 SECTION 10: NOTICES AND DISCLOSURES 90 81 Behavioral HealthCare Parity 90 81 Genetic Information 90 81 Orally Administered Anticancer Medication 90 81 Our Right to Receive and Release Information About You 90 81 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 82 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 25 Chiropractic Services 24 25 Dental Services 24 25 Dialysis Services 28 25 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 25 EARLY INTERVENTION SERVICES (EIS) 30 28 Education - Asthma 31 28 Emergency Room Services 31 28 Experimental or Investigational Services 31 29 Gender Reassignment Affirming Services 32 30 Hearing Services 32 30 Home Health Care 32 30 Hospice Care 33 30 Human Leukocyte Antigen Testing 33 30 Infertility Services 33 31 Infusion Therapy 33 31 Inpatient Services 34 31 Mastectomy Services 34 32 Observation Services 35 32 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 33 Organ Transplants 35 33 Pediatric Neuropsychiatric Disorder Services 34 Physical/Occupational Therapy 36 34 Pregnancy and Maternity Services 36 34 Prescription Drugs 37 34 Preventive Care and Early Detection Services 41 38 Private Duty Nursing Services 43 40 Radiation Therapy/Chemotherapy Services 43 40 Respiratory Therapy 43 40 Skilled Care in a Nursing Facility 43 41 Speech Therapy 43 41 Surgery Services 44 41 Telemedicine Services 45 42 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 44 Vision Care Services 47 44 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Affirming Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 55 Requests for Authorization 59 55 Denials 61 57 Complaints 61 57 Reconsiderations and Appeals 62 58 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 71 Introduction 74 71 Definitions 74 71 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 72 When You Are Covered by More Than One Insurer 75 72 Our Right to Make Payments and Recover Overpayments 77 74 Our Right of Subrogation and/or Reimbursement 78 75 SECTION 8: GLOSSARY 80 77 SECTION 9: CONTACT INFORMATION 88 84 SECTION 10: NOTICES AND DISCLOSURES 90 86 Behavioral HealthCare Parity 90 86 Genetic Information 90 86 Orally Administered Anticancer Medication 90 86 Our Right to Receive and Release Information About You 90 86 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 87 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 25 Chiropractic Services 24 25 Dental Services 24 25 Dialysis Services 28 25 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 25 EARLY INTERVENTION SERVICES (EIS) 30 28 Education - Asthma 31 28 Emergency Room Services 31 28 Experimental or Investigational Services 31 29 Gender Reassignment Affirming Services 32 30 Hearing Services 32 30 Home Health Care 32 30 Hospice Care 33 30 Human Leukocyte Antigen Testing 33 30 Infertility Services 33 31 Infusion Therapy 33 31 Inpatient Services 34 31 Mastectomy Services 34 32 Observation Services 35 32 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 33 Organ Transplants 35 33 Pediatric Neuropsychiatric Disorder Services 34 Physical/Occupational Therapy 36 34 Pregnancy and Maternity Services 36 34 Prescription Drugs 37 34 Preventive Care and Early Detection Services 41 38 Private Duty Nursing Services 43 40 Radiation Therapy/Chemotherapy Services 43 40 Respiratory Therapy 43 40 Skilled Care in a Nursing Facility 43 41 Speech Therapy 43 41 Surgery Services 44 41 Telemedicine Services 45 42 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 44 Vision Care Services 47 44 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Affirming Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 55 Requests for Authorization 59 55 Denials 61 57 Complaints 61 57 Reconsiderations and Appeals 62 58 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 66 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 71 Introduction 74 71 Definitions 74 71 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 72 When You Are Covered by More Than One Insurer 75 72 Our Right to Make Payments and Recover Overpayments 77 74 Our Right of Subrogation and/or Reimbursement 78 75 SECTION 8: GLOSSARY 80 77 SECTION 9: CONTACT INFORMATION 88 84 SECTION 10: NOTICES AND DISCLOSURES 90 86 Behavioral HealthCare Parity 90 86 Genetic Information 90 86 Orally Administered Anticancer Medication 90 86 Our Right to Receive and Release Information About You 90 86 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 87 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 14 How to Use This Agreement 11 14 Contact Us If You Have a Question 11 14 Your Member Identification Card 12 15 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 15 Programs to Keep You Healthy 12 16 About This Agreement 14 17 SECTION 2: ELIGIBILITY 15 18 Who Is an Eligible Person 15 18 When Your Coverage Begins 16 19 Coverage for Members Who Are Hospitalized on Their Effective Date 18 21 How to Add or Remove Coverage for Family Members 18 21 When Your Coverage Ends 18 21 Continuation of Coverage 19 22 SECTION 3: COVERED HEALTHCARE SERVICES 21 24 Ambulance Services 21 25 Autism Services 22 25 Behavioral Health Services 23 26 Cardiac Rehabilitation 24 28 Chiropractic Services 24 28 Dental Services 24 28 Dialysis Services 28 31 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 31 EARLY INTERVENTION SERVICES (EIS) 30 33 Education - Asthma 31 34 Emergency Room Services 31 34 Experimental or Investigational Services 31 34 Gender Reassignment Affirming Services 32 35 Hearing Services 32 35 Home Health Care 32 36 Hospice Care 33 36 Human Leukocyte Antigen Testing 33 36 Infertility Services 33 36 Infusion Therapy 33 37 Inpatient Services 34 37 Mastectomy Services 34 37 Observation Services 35 38 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 38 Organ Transplants 35 39 Pediatric Neuropsychiatric Disorder Services 39 Physical/Occupational Therapy 36 39 Pregnancy and Maternity Services 36 40 Prescription Drugs 37 40 Preventive Care and Early Detection Services 41 44 Private Duty Nursing Services 43 46 Radiation Therapy/Chemotherapy Services 43 46 Respiratory Therapy 43 46 Skilled Care in a Nursing Facility 43 46 Speech Therapy 43 46 Surgery Services 44 47 Telemedicine Services 45 48 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 48 Urgent Care 46 49 Vision Care Services 47 49 SECTION 4: EXCLUSIONS 49 52 Air and Water Ambulance Services 49 52 Behavioral Health Services 49 52 Chiropractic Services 49 52 Dental Services 49 52 Dialysis Services 50 53 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 53 Experimental or Investigational Services 51 54 Gender Reassignment Affirming Services 51 54 Hearing Services 51 54 Home Health Care 51 54 Infertility Services 51 54 Inpatient Services 51 54 Organ Transplants 51 54 Pregnancy and Maternity Services 52 55 Prescription Drugs and Diabetic Equipment or Supplies 52 55 Private Duty Nursing Services 53 56 Surgery Services 53 56 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 57 Therapies 54 57 Vision Care Services 55 58 Providers 55 58 Services Available or Provided from Other Sources 55 58 All Other Exclusions 56 59 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 62 Requests for Authorization 59 62 Denials 61 64 Complaints 61 64 Reconsiderations and Appeals 62 65 Legal Action 65 68 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 70 How to File a Claim 67 70 How Network Providers Are Paid 67 70 How Non-network Providers Are Paid 68 71 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 73 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 78 Introduction 74 78 Definitions 74 78 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 79 When You Are Covered by More Than One Insurer 75 79 Our Right to Make Payments and Recover Overpayments 77 81 Our Right of Subrogation and/or Reimbursement 78 82 SECTION 8: GLOSSARY 80 84 SECTION 9: CONTACT INFORMATION 88 92 SECTION 10: NOTICES AND DISCLOSURES 90 94 Behavioral HealthCare Health Care Parity 90 94 Genetic Information 90 94 Orally Administered Anticancer Medication 90 94 Our Right to Receive and Release Information About You 90 94 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 95 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 11 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 24 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 24 EARLY INTERVENTION SERVICES (EIS) 30 27 Education - Asthma 31 27 Emergency Room Services 31 27 Experimental or Investigational Services 31 28 Gender Reassignment Affirming Services 32 29 Hearing Services 32 29 Home Health Care 32 29 Hospice Care 33 29 Human Leukocyte Antigen Testing 33 29 Infertility Services 33 30 Infusion Therapy 33 30 Inpatient Services 34 30 Mastectomy Services 34 31 Observation Services 35 31 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 32 Organ Transplants 35 32 Pediatric Neuropsychiatric Disorder Services 33 Physical/Occupational Therapy 36 33 Pregnancy and Maternity Services 36 33 Prescription Drugs 37 33 Preventive Care and Early Detection Services 41 37 Private Duty Nursing Services 43 39 Radiation Therapy/Chemotherapy Services 43 39 Respiratory Therapy 43 39 Skilled Care in a Nursing Facility 43 39 Speech Therapy 43 40 Surgery Services 44 40 Telemedicine Services 45 41 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 41 Urgent Care 46 42 Vision Care Services 47 43 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Affirming Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 55 Requests for Authorization 59 55 Denials 61 57 Complaints 61 57 Reconsiderations and Appeals 62 58 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 70 Introduction 74 70 Definitions 74 70 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 71 When You Are Covered by More Than One Insurer 75 71 Our Right to Make Payments and Recover Overpayments 77 73 Our Right of Subrogation and/or Reimbursement 78 74 SECTION 8: GLOSSARY 80 76 SECTION 9: CONTACT INFORMATION 88 84 SECTION 10: NOTICES AND DISCLOSURES 90 86 Behavioral HealthCare Health Care Parity 90 86 Genetic Information 90 86 Orally Administered Anticancer Medication 90 86 Our Right to Receive and Release Information About You 90 86 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 87 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 11 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 16 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 17 Premiums and Grace Periods 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 20 Acupuncture Services 21 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 Physical/Occupational Therapy 36 35 Pregnancy and Maternity Services 36 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Acupuncture Services 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 60 Complaints 60 Appeals 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 65 How to File a Claim 67 65 How Network Providers Are Paid 67 65 How Non-network Providers Are Paid 68 66 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Abortion Services 88 Our Right to Receive and Release Information About You 90 89 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 Continuation of Coverage 17 Premiums and Grace Periods 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 30 Gender Affirming Services 31 Gender Reassignment Services 32 Hearing Services 32 31 Home Health Care 32 31 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 34 Pediatric Neuropsychiatric Disorder Services 35 Physical/Occupational Therapy 36 35 Pregnancy and Maternity Services 36 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 43 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 45 SECTION 4: EXCLUSIONS 49 47 Air and Water Ambulance Services 49 47 Behavioral Health Services 49 47 Chiropractic Services 49 47 Dental Services 49 47 Dialysis Services 50 48 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 48 Experimental or Investigational Services 51 49 Gender Reassignment Affirming Services 51 49 Hearing Services 51 49 Home Health Care 51 49 Infertility Services 51 49 Inpatient Services 51 49 Organ Transplants 51 49 Pregnancy and Maternity Services 52 50 Prescription Drugs and Diabetic Equipment or Supplies 52 50 Private Duty Nursing Services 53 51 Surgery Services 53 51 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 52 Therapies 54 52 Vision Care Services 55 53 Providers 55 53 Services Available or Provided from Other Sources 55 53 All Other Exclusions 56 54 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 57 Requests for Authorization 57 Denials 59 Denials 61 Complaints 61 Reconsiderations and 59 Appeals 62 60 Legal Action 65 63 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 64 How to File a Claim 67 64 How Network Providers Are Paid 67 64 How Non-network Providers Are Paid 68 65 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 67 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Health Care Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Abortion Services 88 Our Right to Receive and Release Information About You 90 88 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 14 How to Use This Agreement 11 14 Contact Us If You Have a Question 11 14 Your Member Identification Card 12 15 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 15 Programs to Keep You Healthy 12 16 About This Agreement 14 17 SECTION 2: ELIGIBILITY 15 18 Who Is an Eligible Person 15 18 When Your Coverage Begins 16 19 Coverage for Members Who Are Hospitalized on Their Effective Date 18 21 How to Add or Remove Coverage for Family Members 18 21 When Your Coverage Ends 18 21 Continuation of Coverage 19 22 SECTION 3: COVERED HEALTHCARE SERVICES 21 24 Ambulance Services 21 25 Autism Services 22 25 Behavioral Health Services 23 26 Cardiac Rehabilitation 24 28 Chiropractic Services 24 28 Dental Services 24 28 Dialysis Services 28 31 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 31 EARLY INTERVENTION SERVICES (EIS) 30 33 Education - Asthma 31 34 Emergency Room Services 31 34 Experimental or Investigational Services 31 34 Gender Reassignment Affirming Services 32 35 Hearing Services 32 35 Home Health Care 32 36 Hospice Care 33 36 Human Leukocyte Antigen Testing 33 36 Infertility Services 33 36 Infusion Therapy 33 37 Inpatient Services 34 37 Mastectomy Services 34 37 Observation Services 35 38 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 38 Organ Transplants 35 39 Pediatric Neuropsychiatric Disorder Services 39 Physical/Occupational Therapy 36 39 Pregnancy and Maternity Services 36 40 Prescription Drugs 37 40 Preventive Care and Early Detection Services 41 44 Private Duty Nursing Services 43 46 Radiation Therapy/Chemotherapy Services 43 46 Respiratory Therapy 43 46 Skilled Care in a Nursing Facility 43 46 Speech Therapy 43 46 Surgery Services 44 47 Telemedicine Services 45 48 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 48 Urgent Care 46 49 Vision Care Services 47 49 SECTION 4: EXCLUSIONS 49 52 Air and Water Ambulance Services 49 52 Behavioral Health Services 49 52 Chiropractic Services 49 52 Dental Services 49 52 Dialysis Services 50 53 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 53 Experimental or Investigational Services 51 54 Gender Reassignment Affirming Services 51 54 Hearing Services 51 54 Home Health Care 51 54 Infertility Services 51 54 Inpatient Services 51 54 Organ Transplants 51 54 Pregnancy and Maternity Services 52 55 Prescription Drugs and Diabetic Equipment or Supplies 52 55 Private Duty Nursing Services 53 56 Surgery Services 53 56 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 57 Therapies 54 57 Vision Care Services 55 58 Providers 55 58 Services Available or Provided from Other Sources 55 58 All Other Exclusions 56 59 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 62 Requests for Authorization 59 62 Denials 61 64 Complaints 61 64 Reconsiderations and Appeals 62 65 Legal Action 65 68 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 70 How to File a Claim 67 70 How Network Providers Are Paid 67 70 How Non-network Providers Are Paid 68 71 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 78 Introduction 74 78 Definitions 74 78 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 79 When You Are Covered by More Than One Insurer 75 79 Our Right to Make Payments and Recover Overpayments 77 81 Our Right of Subrogation and/or Reimbursement 78 82 SECTION 8: GLOSSARY 80 84 SECTION 9: CONTACT INFORMATION 88 92 SECTION 10: NOTICES AND DISCLOSURES 90 94 Behavioral HealthCare Health Care Parity 90 94 Genetic Information 90 94 Orally Administered Anticancer Medication 90 94 Our Right to Receive and Release Information About You 90 94 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 95 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 15 How to Use This Agreement 11 15 Contact Us If You Have a Question 11 15 Your Member Identification Card 12 16 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 16 Programs to Keep You Healthy 12 17 About This Agreement 14 18 SECTION 2: ELIGIBILITY 15 19 Who Is an Eligible Person 15 19 When Your Coverage Begins 16 20 Coverage for Members Who Are Hospitalized on Their Effective Date 18 22 How to Add or Remove Coverage for Family Members 18 22 When Your Coverage Ends 18 22 Continuation of Coverage 19 23 SECTION 3: COVERED HEALTHCARE SERVICES 21 25 Ambulance Services 21 26 Autism Services 22 26 Behavioral Health Services 23 27 Cardiac Rehabilitation 24 29 Chiropractic Services 24 29 Dental Services 24 29 Dialysis Services 28 32 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 32 EARLY INTERVENTION SERVICES (EIS) 30 34 Education - Asthma 31 35 Emergency Room Services 31 35 Experimental or Investigational Services 31 35 Gender Reassignment Affirming Services 32 36 Hearing Services 32 36 Home Health Care 32 37 Hospice Care 33 37 Human Leukocyte Antigen Testing 33 37 Infertility Services 33 37 Infusion Therapy 33 38 Inpatient Services 34 38 Mastectomy Services 34 38 Observation Services 35 39 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 39 Organ Transplants 35 40 Pediatric Neuropsychiatric Disorder Services 40 Physical/Occupational Therapy 36 40 Pregnancy and Maternity Services 36 41 Prescription Drugs 37 41 Preventive Care and Early Detection Services 41 45 Private Duty Nursing Services 43 47 Radiation Therapy/Chemotherapy Services 43 47 Respiratory Therapy 43 47 Skilled Care in a Nursing Facility 43 47 Speech Therapy 43 47 Surgery Services 44 48 Telemedicine Services 45 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 49 Urgent Care 46 50 Vision Care Services 47 50 SECTION 4: EXCLUSIONS 49 53 Air and Water Ambulance Services 49 53 Behavioral Health Services 49 53 Chiropractic Services 49 53 Dental Services 49 53 Dialysis Services 50 54 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 54 Experimental or Investigational Services 51 55 Gender Reassignment Affirming Services 51 55 Hearing Services 51 55 Home Health Care 51 55 Infertility Services 51 55 Inpatient Services 51 55 Organ Transplants 51 55 Pregnancy and Maternity Services 52 56 Prescription Drugs and Diabetic Equipment or Supplies 52 56 Private Duty Nursing Services 53 57 Surgery Services 53 57 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 58 Therapies 54 58 Vision Care Services 55 59 Providers 55 59 Services Available or Provided from Other Sources 55 59 All Other Exclusions 56 60 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 63 Requests for Authorization 59 63 Denials 61 65 Complaints 61 65 Reconsiderations and Appeals 62 66 Legal Action 65 69 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 71 How to File a Claim 67 71 How Network Providers Are Paid 67 71 How Non-network Providers Are Paid 68 72 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 74 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 79 Introduction 74 79 Definitions 74 79 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 80 When You Are Covered by More Than One Insurer 75 80 Our Right to Make Payments and Recover Overpayments 77 82 Our Right of Subrogation and/or Reimbursement 78 83 SECTION 8: GLOSSARY 80 85 SECTION 9: CONTACT INFORMATION 88 93 SECTION 10: NOTICES AND DISCLOSURES 90 95 Behavioral HealthCare Health Care Parity 90 95 Genetic Information 90 95 Orally Administered Anticancer Medication 90 95 Our Right to Receive and Release Information About You 90 95 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 96 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 15 How to Use This Agreement 11 15 Contact Us If You Have a Question 11 15 Your Member Identification Card 12 16 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 16 Programs to Keep You Healthy 12 17 About This Agreement 14 18 SECTION 2: ELIGIBILITY 15 19 Who Is an Eligible Person 15 19 When Your Coverage Begins 16 20 Coverage for Members Who Are Hospitalized on Their Effective Date 18 22 How to Add or Remove Coverage for Family Members 18 22 When Your Coverage Ends 18 22 Continuation of Coverage 19 23 SECTION 3: COVERED HEALTHCARE SERVICES 21 25 Ambulance Services 21 26 Autism Services 22 26 Behavioral Health Services 23 27 Cardiac Rehabilitation 24 29 Chiropractic Services 24 29 Dental Services 24 29 Dialysis Services 28 29 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 29 EARLY INTERVENTION SERVICES (EIS) 30 32 Education - Asthma 31 32 Emergency Room Services 31 32 Experimental or Investigational Services 31 33 Gender Reassignment Affirming Services 32 34 Hearing Services 32 34 Home Health Care 32 34 Hospice Care 33 34 Human Leukocyte Antigen Testing 33 34 Infertility Services 33 35 Infusion Therapy 33 35 Inpatient Services 34 35 Mastectomy Services 34 36 Observation Services 35 36 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 37 Organ Transplants 35 37 Pediatric Neuropsychiatric Disorder Services 38 Physical/Occupational Therapy 36 38 Pregnancy and Maternity Services 36 38 Prescription Drugs 37 39 Preventive Care and Early Detection Services 41 42 Private Duty Nursing Services 43 44 Radiation Therapy/Chemotherapy Services 43 44 Respiratory Therapy 43 45 Skilled Care in a Nursing Facility 43 45 Speech Therapy 43 45 Surgery Services 44 45 Telemedicine Services 45 46 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 47 Urgent Care 46 48 Vision Care Services 47 48 SECTION 4: EXCLUSIONS 49 50 Air and Water Ambulance Services 49 50 Behavioral Health Services 49 50 Chiropractic Services 49 50 Dental Services 49 50 Dialysis Services 50 51 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 51 Experimental or Investigational Services 51 52 Gender Reassignment Affirming Services 51 52 Hearing Services 51 52 Home Health Care 51 52 Infertility Services 51 52 Inpatient Services 51 52 Organ Transplants 51 52 Pregnancy and Maternity Services 52 53 Prescription Drugs and Diabetic Equipment or Supplies 52 53 Private Duty Nursing Services 53 54 Surgery Services 53 54 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 55 Therapies 54 55 Vision Care Services 55 56 Providers 55 56 Services Available or Provided from Other Sources 55 56 All Other Exclusions 56 57 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 60 Requests for Authorization 59 60 Denials 61 62 Complaints 61 62 Reconsiderations and Appeals 62 63 Legal Action 65 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 How to File a Claim 67 How Network Providers Are Paid 67 How Non-network Providers Are Paid 68 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 Introduction 74 Definitions 74 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 When You Are Covered by More Than One Insurer 75 Our Right to Make Payments and Recover Overpayments 77 Our Right of Subrogation and/or Reimbursement 78 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 Behavioral HealthCare Parity 90 Genetic Information 90 Orally Administered Anticancer Medication 90 Our Right to Receive and Release Information About You 90 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 SUMMARY OF MEDICAL BENEFITS66

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 14 How to Use This Agreement 11 14 Contact Us If You Have a Question 11 14 Your Member Identification Card 12 15 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 15 Programs to Keep You Healthy 12 16 About This Agreement 14 17 SECTION 2: ELIGIBILITY 15 18 Who Is an Eligible Person 15 18 When Your Coverage Begins 16 19 Coverage for Members Who Are Hospitalized on Their Effective Date 18 21 How to Add or Remove Coverage for Family Members 18 21 When Your Coverage Ends 18 21 Continuation of Coverage 19 22 SECTION 3: COVERED HEALTHCARE SERVICES 21 24 Ambulance Services 21 25 Autism Services 22 25 Behavioral Health Services 23 26 Cardiac Rehabilitation 24 28 Chiropractic Services 24 28 Dental Services 24 28 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 31 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 32 Gender Reassignment Affirming Services 32 33 Hearing Services 32 33 Home Health Care 32 33 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 34 Infusion Therapy 33 34 Inpatient Services 34 Mastectomy Services 34 35 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 36 Organ Transplants 35 36 Pediatric Neuropsychiatric Disorder Services 37 Physical/Occupational Therapy 36 37 Pregnancy and Maternity Services 36 37 Prescription Drugs 37 38 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 44 Skilled Care in a Nursing Facility 43 44 Speech Therapy 43 44 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 46 Urgent Care 46 47 Vision Care Services 47 SECTION 4: EXCLUSIONS 49 Air and Water Ambulance Services 49 Behavioral Health Services 49 Chiropractic Services 49 Dental Services 49 Dialysis Services 50 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 Experimental or Investigational Services 51 Gender Reassignment Affirming Services 51 Hearing Services 51 Home Health Care 51 Infertility Services 51 Inpatient Services 51 Organ Transplants 51 Pregnancy and Maternity Services 52 Prescription Drugs and Diabetic Equipment or Supplies 52 Private Duty Nursing Services 53 Surgery Services 53 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 Therapies 54 Vision Care Services 55 Providers 55 Services Available or Provided from Other Sources 55 All Other Exclusions 56 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 Requests for Authorization 59 Denials 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 How to File a Claim 67 How Network Providers Are Paid 67 How Non-network Providers Are Paid 68 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 70 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 75 Introduction 74 75 Definitions 74 75 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 76 When You Are Covered by More Than One Insurer 75 76 Our Right to Make Payments and Recover Overpayments 77 78 Our Right of Subrogation and/or Reimbursement 78 79 SECTION 8: GLOSSARY 80 81 SECTION 9: CONTACT INFORMATION 88 89 SECTION 10: NOTICES AND DISCLOSURES 90 91 Behavioral HealthCare Health Care Parity 90 91 Genetic Information 90 91 Orally Administered Anticancer Medication 90 91 Our Right to Receive and Release Information About You 90 91 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 92 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 25 Chiropractic Services 24 25 Dental Services 24 25 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 32 Gender Reassignment Affirming Services 32 33 Hearing Services 32 34 Home Health Care 32 34 Hospice Care 33 34 Human Leukocyte Antigen Testing 33 34 Infertility Services 33 34 Infusion Therapy 33 35 Inpatient Services 34 35 Mastectomy Services 34 36 Observation Services 35 36 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 36 Organ Transplants 35 37 Pediatric Neuropsychiatric Disorder Services 38 Physical/Occupational Therapy 36 38 Pregnancy and Maternity Services 36 38 Prescription Drugs 37 38 Preventive Care and Early Detection Services 41 42 Private Duty Nursing Services 43 45 Radiation Therapy/Chemotherapy Services 43 45 Respiratory Therapy 43 45 Skilled Care in a Nursing Facility 43 45 Speech Therapy 43 45 Surgery Services 44 45 Telemedicine Services 45 46 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 47 Urgent Care 46 48 Vision Care Services 47 49 SECTION 4: EXCLUSIONS 49 51 Air and Water Ambulance Services 49 51 Behavioral Health Services 49 51 Chiropractic Services 49 51 Dental Services 49 51 Dialysis Services 50 52 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 52 Experimental or Investigational Services 51 53 Gender Reassignment Affirming Services 51 53 Hearing Services 51 53 Home Health Care 51 53 Infertility Services 51 53 Inpatient Services 51 53 Organ Transplants 51 53 Pregnancy and Maternity Services 52 54 Prescription Drugs and Diabetic Equipment or Supplies 52 54 Private Duty Nursing Services 53 55 Surgery Services 53 55 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 56 Therapies 54 57 Vision Care Services 55 57 Providers 55 57 Services Available or Provided from Other Sources 55 58 All Other Exclusions 56 58 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 61 Requests for Authorization 59 61 Denials 61 63 Complaints 61 63 Reconsiderations and Appeals 62 64 Legal Action 65 67 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 69 How to File a Claim 67 69 How Network Providers Are Paid 67 69 How Non-network Providers Are Paid 68 70 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 72 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 76 Introduction 74 76 Definitions 74 76 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 77 When You Are Covered by More Than One Insurer 75 77 Our Right to Make Payments and Recover Overpayments 77 79 Our Right of Subrogation and/or Reimbursement 78 80 SECTION 8: GLOSSARY 80 82 SECTION 9: CONTACT INFORMATION 88 90 SECTION 10: NOTICES AND DISCLOSURES 90 92 Behavioral HealthCare Health Care Parity 90 92 Genetic Information 90 92 Orally Administered Anticancer Medication 90 92 Our Right to Receive and Release Information About You 90 92 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 93 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 17 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 18 17 Continuation of Coverage 19 18 SECTION 3: COVERED HEALTHCARE SERVICES 21 20 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 23 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 24 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 24 EARLY INTERVENTION SERVICES (EIS) 30 27 Education - Asthma 31 27 Emergency Room Services 31 27 Experimental or Investigational Services 31 28 Gender Reassignment Services 32 29 Hearing Services 32 29 Home Health Care 32 29 Hospice Care 33 29 Human Leukocyte Antigen Testing 33 29 Infertility Services 33 30 Infusion Therapy 33 30 Inpatient Services 34 30 Mastectomy Services 34 31 Observation Services 35 31 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 32 Organ Transplants 35 32 Physical/Occupational Therapy 36 33 Pregnancy and Maternity Services 36 33 Prescription Drugs 37 33 Preventive Care and Early Detection Services 41 37 Private Duty Nursing Services 43 39 Radiation Therapy/Chemotherapy Services 43 39 Respiratory Therapy 43 40 Skilled Care in a Nursing Facility 43 40 Speech Therapy 43 40 Surgery Services 44 40 Telemedicine Services 45 41 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 42 Urgent Care 46 43 Vision Care Services 47 43 SECTION 4: EXCLUSIONS 49 45 Air and Water Ambulance Services 49 45 Behavioral Health Services 49 45 Chiropractic Services 49 45 Dental Services 49 45 Dialysis Services 50 46 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 46 Experimental or Investigational Services 51 47 Gender Reassignment Services 51 47 Hearing Services 51 47 Home Health Care 51 47 Infertility Services 51 47 Inpatient Services 51 47 Organ Transplants 51 47 Pregnancy and Maternity Services 52 48 Prescription Drugs and Diabetic Equipment or Supplies 52 48 Private Duty Nursing Services 53 49 Surgery Services 53 49 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 50 Therapies 54 50 Vision Care Services 55 51 Providers 55 51 Services Available or Provided from Other Sources 55 51 All Other Exclusions 56 52 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 55 Requests for Authorization 59 55 Denials 61 57 Complaints 61 57 Reconsiderations and Appeals 62 58 Legal Action 65 61 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 63 How to File a Claim 67 63 How Network Providers Are Paid 67 63 How Non-network Providers Are Paid 68 64 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 66 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 70 Introduction 74 70 Definitions 74 70 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 71 When You Are Covered by More Than One Insurer 75 71 Our Right to Make Payments and Recover Overpayments 77 73 Our Right of Subrogation and/or Reimbursement 78 74 SECTION 8: GLOSSARY 80 76 SECTION 9: CONTACT INFORMATION 88 83 SECTION 10: NOTICES AND DISCLOSURES 90 85 Behavioral HealthCare Parity 90 85 Genetic Information 90 85 Orally Administered Anticancer Medication 90 85 Our Right to Receive and Release Information About You 90 85 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 86 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 13 How to Use This Agreement 11 13 Contact Us If You Have a Question 11 13 Your Member Identification Card 12 14 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 14 Programs to Keep You Healthy 12 15 About This Agreement 14 16 SECTION 2: ELIGIBILITY 15 18 Who Is an Eligible Person 15 18 When Your Coverage Begins 16 19 Coverage for Members Who Are Hospitalized on Their Effective Date 18 21 How to Add or Remove Coverage for Family Members 18 21 When Your Coverage Ends 18 Continuation of Coverage 19 21 Premiums and Grace Periods 22 SECTION 3: COVERED HEALTHCARE SERVICES 21 24 Acupuncture Services 25 Ambulance Services 21 25 Autism Services 22 25 Behavioral Health Services 23 26 Cardiac Rehabilitation 24 28 Chiropractic Services 24 28 Dental Services 24 28 Dialysis Services 28 31 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 31 EARLY INTERVENTION SERVICES (EIS) 30 33 Education - Asthma 31 34 Emergency Room Services 31 34 Experimental or Investigational Services 31 34 Gender Reassignment Services 32 35 Hearing Services 32 35 Home Health Care 32 35 Hospice Care 33 36 Human Leukocyte Antigen Testing 33 36 Infertility Services 33 36 Infusion Therapy 33 37 Inpatient Services 34 37 Mastectomy Services 34 Observation Services 35 37 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 38 Organ Transplants 35 38 Physical/Occupational Therapy 36 39 Pregnancy and Maternity Services 36 39 Prescription Drugs 37 and Diabetic Equipment or Supplies 39 Preventive Care and Early Detection Services 41 43 Private Duty Nursing Services 43 45 Radiation Therapy/Chemotherapy Services 43 45 Respiratory Therapy 43 45 Skilled Care in a Nursing Facility 43 45 Speech Therapy 43 46 Surgery Services 44 46 Telemedicine Services 45 47 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 47 Urgent Care 46 48 Vision Care Services 47 48 SECTION 4: EXCLUSIONS 49 51 Acupuncture Services 51 Air and Water Ambulance Services 49 51 Behavioral Health Services 49 51 Chiropractic Services 49 51 Dental Services 49 52 Dialysis Services 50 52 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 52 Experimental or Investigational Services 51 53 Gender Reassignment Services 51 53 Hearing Services 51 53 Home Health Care 51 53 Infertility Services 51 53 Inpatient Services 51 53 Organ Transplants 51 54 Pregnancy and Maternity Services 52 54 Prescription Drugs and Diabetic Equipment or Supplies 52 54 Private Duty Nursing Services 53 55 Surgery Services 53 55 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 56 Therapies 54 57 Vision Care Services 55 57 Providers 55 57 Services Available or Provided from Other Sources 55 58 All Other Exclusions 56 58 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 61 Requests for Authorization 59 61 Denials 61 63 Complaints 61 Reconsiderations and 63 Appeals 62 64 Legal Action 65 67 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 68 How to File a Claim 67 68 How Network Providers Are Paid 67 68 How Non-network Providers Are Paid 68 69 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 70 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 Introduction 74 Definitions 74 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 When You Are Covered by More Than One Insurer 75 Our Right to Make Payments and Recover Overpayments 77 Our Right of Subrogation and/or Reimbursement 78 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 Behavioral HealthCare Parity 90 Genetic Information 90 Orally Administered Anticancer Medication 90 Our Right to Receive and Release Information About You 90 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 25 Dental Services 24 25 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 Gender Reassignment Services 32 Hearing Services 32 Home Health Care 32 33 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 34 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 36 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 37 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 50 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 53 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 54 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 61 60 Complaints 61 60 Reconsiderations and Appeals 62 61 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 66 How to File a Claim 67 66 How Network Providers Are Paid 67 66 How Non-network Providers Are Paid 68 67 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 68 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Our Right to Receive and Release Information About You 90 88 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Acupuncture Services 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 25 Dental Services 24 25 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 Gender Reassignment Services 32 Hearing Services 32 Home Health Care 32 33 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 34 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 36 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 37 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Acupuncture Services 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 61 60 Complaints 61 60 Reconsiderations and Appeals 62 61 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 66 How to File a Claim 67 66 How Network Providers Are Paid 67 66 How Non-network Providers Are Paid 68 67 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Our Right to Receive and Release Information About You 90 88 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Acupuncture Services 21 Ambulance Services 21 22 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 25 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 Gender Reassignment Services 32 Hearing Services 32 Home Health Care 32 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 34 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 SECTION 4: EXCLUSIONS 49 Acupuncture Services 49 Air and Water Ambulance Services 49 Behavioral Health Services 49 Chiropractic Services 49 Dental Services 49 Dialysis Services 50 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 Experimental or Investigational Services 51 Gender Reassignment Services 51 Hearing Services 51 Home Health Care 51 Infertility Services 51 Inpatient Services 51 Organ Transplants 51 52 Pregnancy and Maternity Services 52 Prescription Drugs and Diabetic Equipment or Supplies 52 Private Duty Nursing Services 53 Surgery Services 53 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 Therapies 54 55 Vision Care Services 55 Providers 55 Services Available or Provided from Other Sources 55 56 All Other Exclusions 56 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 Requests for Authorization 59 Denials 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 How to File a Claim 67 How Network Providers Are Paid 67 How Non-network Providers Are Paid 68 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 70 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 Introduction 74 Definitions 74 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 When You Are Covered by More Than One Insurer 75 Our Right to Make Payments and Recover Overpayments 77 Our Right of Subrogation and/or Reimbursement 78 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 Behavioral HealthCare Parity 90 Genetic Information 90 Orally Administered Anticancer Medication 90 Our Right to Receive and Release Information About You 90 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 14 How to Use This Agreement 11 14 Contact Us If You Have a Question 11 14 Your Member Identification Card 12 15 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 15 Programs to Keep You Healthy 12 16 About This Agreement 14 17 SECTION 2: ELIGIBILITY 15 18 Who Is an Eligible Person 15 18 When Your Coverage Begins 16 19 Coverage for Members Who Are Hospitalized on Their Effective Date 18 21 How to Add or Remove Coverage for Family Members 18 21 When Your Coverage Ends 18 21 Continuation of Coverage 19 22 SECTION 3: COVERED HEALTHCARE SERVICES 21 24 Ambulance Services 21 25 Autism Services 22 25 Behavioral Health Services 23 26 Cardiac Rehabilitation 24 28 Chiropractic Services 24 28 Dental Services 24 28 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 31 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 32 Gender Reassignment Affirming Services 32 33 Hearing Services 32 34 Home Health Care 32 34 Hospice Care 33 34 Human Leukocyte Antigen Testing 33 34 Infertility Services 33 35 Infusion Therapy 33 35 Inpatient Services 34 35 Mastectomy Services 34 36 Observation Services 35 36 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 37 Organ Transplants 35 37 Pediatric Neuropsychiatric Disorder Services 38 Physical/Occupational Therapy 36 38 Pregnancy and Maternity Services 36 38 Prescription Drugs 37 38 Preventive Care and Early Detection Services 41 42 Private Duty Nursing Services 43 45 Radiation Therapy/Chemotherapy Services 43 45 Respiratory Therapy 43 45 Skilled Care in a Nursing Facility 43 45 Speech Therapy 43 45 Surgery Services 44 46 Telemedicine Services 45 46 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 47 Urgent Care 46 48 Vision Care Services 47 49 SECTION 4: EXCLUSIONS 49 51 Air and Water Ambulance Services 49 51 Behavioral Health Services 49 51 Chiropractic Services 49 51 Dental Services 49 51 Dialysis Services 50 52 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 52 Experimental or Investigational Services 51 53 Gender Reassignment Affirming Services 51 53 Hearing Services 51 53 Home Health Care 51 53 Infertility Services 51 53 Inpatient Services 51 53 Organ Transplants 51 53 Pregnancy and Maternity Services 52 54 Prescription Drugs and Diabetic Equipment or Supplies 52 54 Private Duty Nursing Services 53 55 Surgery Services 53 55 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 56 Therapies 54 57 Vision Care Services 55 57 Providers 55 57 Services Available or Provided from Other Sources 55 58 All Other Exclusions 56 58 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 61 Requests for Authorization 59 61 Denials 61 63 Complaints 61 63 Reconsiderations and Appeals 62 64 Legal Action 65 67 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 69 How to File a Claim 67 69 How Network Providers Are Paid 67 69 How Non-network Providers Are Paid 68 70 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 72 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 77 Introduction 74 77 Definitions 74 77 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 78 When You Are Covered by More Than One Insurer 75 78 Our Right to Make Payments and Recover Overpayments 77 80 Our Right of Subrogation and/or Reimbursement 78 81 SECTION 8: GLOSSARY 80 83 SECTION 9: CONTACT INFORMATION 88 90 SECTION 10: NOTICES AND DISCLOSURES 90 92 Behavioral HealthCare Health Care Parity 90 92 Genetic Information 90 92 Orally Administered Anticancer Medication 90 92 Our Right to Receive and Release Information About You 90 92 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 93 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 Gender Reassignment Services 32 Hearing Services 32 Home Health Care 32 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 SECTION 4: EXCLUSIONS 49 Air and Water Ambulance Services 49 Behavioral Health Services 49 Chiropractic Services 49 Dental Services 49 Dialysis Services 50 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 Experimental or Investigational Services 51 Gender Reassignment Services 51 Hearing Services 51 Home Health Care 51 Infertility Services 51 Inpatient Services 51 Organ Transplants 51 Pregnancy and Maternity Services 52 Prescription Drugs and Diabetic Equipment or Supplies 52 Private Duty Nursing Services 53 Surgery Services 53 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 Therapies 54 Vision Care Services 55 Providers 55 Services Available or Provided from Other Sources 55 All Other Exclusions 56 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 Requests for Authorization 59 Denials 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 How to File a Claim 67 How Network Providers Are Paid 67 How Non-network Providers Are Paid 68 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 70 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 Introduction 74 Definitions 74 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 When You Are Covered by More Than One Insurer 75 Our Right to Make Payments and Recover Overpayments 77 Our Right of Subrogation and/or Reimbursement 78 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 Behavioral HealthCare Parity 90 Genetic Information 90 Orally Administered Anticancer Medication 90 Our Right to Receive and Release Information About You 90 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 SUMMARY OF MEDICAL BENEFITS

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 Gender Reassignment Services 32 Hearing Services 32 Home Health Care 32 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 SECTION 4: EXCLUSIONS 49 Air and Water Ambulance Services 49 Behavioral Health Services 49 Chiropractic Services 49 Dental Services 49 Dialysis Services 50 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 Experimental or Investigational Services 51 Gender Reassignment Services 51 Hearing Services 51 Home Health Care 51 Infertility Services 51 Inpatient Services 51 Organ Transplants 51 Pregnancy and Maternity Services 52 Prescription Drugs and Diabetic Equipment or Supplies 52 Private Duty Nursing Services 53 Surgery Services 53 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 Therapies 54 Vision Care Services 55 Providers 55 Services Available or Provided from Other Sources 55 All Other Exclusions 56 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 Requests for Authorization 59 Denials 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 How to File a Claim 67 How Network Providers Are Paid 67 How Non-network Providers Are Paid 68 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 Introduction 74 Definitions 74 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 When You Are Covered by More Than One Insurer 75 Our Right to Make Payments and Recover Overpayments 77 Our Right of Subrogation and/or Reimbursement 78 SECTION 8: GLOSSARY 80 SECTION 9: CONTACT INFORMATION 88 SECTION 10: NOTICES AND DISCLOSURES 90 Behavioral HealthCare Parity 90 Genetic Information 90 Orally Administered Anticancer Medication 90 Our Right to Receive and Release Information About You 90 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 SUMMARY OF MEDICAL BENEFITSBENEFITS ‌

INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 10 How to Use This Agreement 11 10 Contact Us If You Have a Question 11 10 Your Member Identification Card 12 11 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 11 Programs to Keep You Healthy 12 11 About This Agreement 14 13 SECTION 2: ELIGIBILITY 15 14 Who Is an Eligible Person 15 14 When Your Coverage Begins 16 15 Coverage for Members Who Are Hospitalized on Their Effective Date 18 16 How to Add or Remove Coverage for Family Members 18 17 When Your Coverage Ends 17 Premiums and Grace Periods 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 20 Acupuncture Services 21 Ambulance Services 21 Autism Services 22 21 Behavioral Health Services 23 22 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 27 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 27 EARLY INTERVENTION SERVICES (EIS) 30 29 Education - Asthma 31 30 Emergency Room Services 31 30 Experimental or Investigational Services 31 30 Gender Reassignment Services 32 31 Hearing Services 32 31 Home Health Care 32 Hospice Care 33 32 Human Leukocyte Antigen Testing 33 32 Infertility Services 33 32 Infusion Therapy 33 Inpatient Services 34 33 Mastectomy Services 34 33 Observation Services 35 34 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 34 Organ Transplants 35 Physical/Occupational Therapy 36 35 Pregnancy and Maternity Services 36 Prescription Drugs 37 36 Preventive Care and Early Detection Services 41 40 Private Duty Nursing Services 43 42 Radiation Therapy/Chemotherapy Services 43 42 Respiratory Therapy 43 42 Skilled Care in a Nursing Facility 43 42 Speech Therapy 43 42 Surgery Services 44 43 Telemedicine Services 45 44 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 44 Urgent Care 46 45 Vision Care Services 47 46 SECTION 4: EXCLUSIONS 49 48 Acupuncture Services 48 Air and Water Ambulance Services 49 48 Behavioral Health Services 49 48 Chiropractic Services 49 48 Dental Services 49 48 Dialysis Services 50 49 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 49 Experimental or Investigational Services 51 50 Gender Reassignment Services 51 50 Hearing Services 51 50 Home Health Care 51 50 Infertility Services 51 50 Inpatient Services 51 50 Organ Transplants 51 Pregnancy and Maternity Services 52 51 Prescription Drugs and Diabetic Equipment or Supplies 52 51 Private Duty Nursing Services 53 52 Surgery Services 53 52 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 53 Therapies 54 Vision Care Services 55 54 Providers 55 54 Services Available or Provided from Other Sources 55 All Other Exclusions 56 55 SECTION 5: REQUESTS FOR AUTHORIZATION, DENIALS, COMPLAINTS, AND APPEALS 59 58 Requests for Authorization 59 58 Denials 60 Complaints 60 Appeals 61 Complaints 61 Reconsiderations and Appeals 62 Legal Action 65 64 SECTION 6: CLAIM FILING AND PROVIDER PAYMENTS 67 65 How to File a Claim 67 65 How Network Providers Are Paid 67 65 How Non-network Providers Are Paid 68 66 How BlueCard Providers Are Paid: Coverage for Services Provided Outside Our Service Xxxx 00 Area 67 SECTION 7: COORDINATION OF BENEFITS AND SUBROGATION 74 72 Introduction 74 72 Definitions 74 72 WHEN YOU HAVE MORE THAN ONE PLAN WITH BCBSRI 75 73 When You Are Covered by More Than One Insurer 75 73 Our Right to Make Payments and Recover Overpayments 77 75 Our Right of Subrogation and/or Reimbursement 78 76 SECTION 8: GLOSSARY 80 78 SECTION 9: CONTACT INFORMATION 88 86 SECTION 10: NOTICES AND DISCLOSURES 90 88 Behavioral HealthCare Parity 90 88 Genetic Information 90 88 Orally Administered Anticancer Medication 90 88 Abortion Services 88 Our Right to Receive and Release Information About You 90 89 Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act 91 89 SUMMARY OF MEDICAL BENEFITS