Common use of Private Duty Nursing Services Clause in Contracts

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 20% - After deductible Lab and pathology services. $25 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 20% - After deductible Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 20% - After deductible Non-routine eye exam $40 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 200% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 40 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 100 20% - After deductible Lab and pathology services. $25 50 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 20% - After deductible Urgent Care Urgent care services $100 150 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 50 20% - After deductible Non-routine eye exam $40 50 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 0% 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 15 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 20% - After deductible Lab and pathology services. $25 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 20% - After deductible Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 20% - After deductible Non-routine eye exam $40 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.pay

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 0% 20% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. $20 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 50 20% - After deductible Lab and pathology services. $25 20 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible $20 20% - After deductible Urgent Care Urgent care services $100 75 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 0 20% - After deductible Non-routine eye exam $40 0 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 10 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 20% - After deductible Lab and pathology services. $25 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 20% - After deductible Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 20% - After deductible Non-routine eye exam $40 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient Outpatient 0% - After deductible 20% - After deductible Outpatient In a physician’s office 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. Limited to 30 speech therapy visits per plan year. 20% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 0% 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Flex Plan (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 0% 20% - After deductible Lab and pathology services. $25 0% 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 20% - After deductible Urgent Care Urgent care services $100 50 The level of coverage is the same as network providercare coordinated by your primary care physician and permitted self-referrals. Vision Care Services Vision Routine vision exam - One one routine eye vision exam per member per plan year. $40 50 20% - After deductible Non-routine eye vision exam $40 50 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 15 20% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service healthcareservice being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 20% - After deductible Lab and pathology services. $25 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 20% - After deductible Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 20% - After deductible Non-routine eye exam $40 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 200% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 0% - After deductible Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 20% - After deductible Lab and pathology services. $25 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 20% - After deductible Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 20% - After deductible Non-routine eye exam $40 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.pay

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 0% 20% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. $25 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 20% - After deductible Lab and pathology services. $25 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible $25 20% - After deductible Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 0 20% - After deductible Non-routine eye exam $40 0 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Private Duty Nursing Services. Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 0% 20% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $75 20% - After deductible Lab and pathology services. $25 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment 0% - After deductible $25 20% - After deductible Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $40 0 20% - After deductible Non-routine eye exam $40 0 20% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.Covered