Common use of Radiation Therapy/Chemotherapy Services Clause in Contracts

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a 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 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 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 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 the amount you pay See the covered healthcare service being provided for the amount you pay 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 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 40% - After deductible Not Covered Sleep studies.. * 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment 0% - After deductible 40Not Covered Urgent Care Urgent care services 0% - After deductibledeductible The level of coverage is the same as network provider. Vision Care Services Routine Vision Exam One routine vision exam per member per plan year 0% - After deductible Not Covered One routine vision exam when performed to treat members with diabetes. 0% - After deductible Not Covered Non-routine vision exam 0% - After deductible Not Covered 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% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible 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, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 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 the amount you pay See the covered healthcare service being provided for the amount you pay 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 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 40% - After deductible Not Covered Sleep studies.. * 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment 0% - After deductible 40Not Covered Urgent Care Urgent care services 0% - After deductibledeductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible Not Covered Non-routine eye exam 0% - After deductible Not Covered 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% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible 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, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible Deductible 40% - After deductible Deductible In a physiciandoctor’s office 020% - After deductible Deductible 40% - After deductible Deductible Respiratory Therapy Inpatient 020% - After deductible Deductible 40% - After deductible Deductible Outpatient 020% - After deductible Deductible 40% - After deductible Deductible Skilled Nursing Facility Care in a Nursing Facility* Skilled or sub-acute care 0care* 20% - After deductible Deductible 40% - After deductible Deductible Speech Therapy Outpatient hospitalOutpatient/in a physician’sdoctor’s/therapist’s office* Limited to thirty (30) visits per member per plan year. 0% - After deductible $40 40% - After deductible Deductible Surgery Services* Services Inpatient physician doctor services 020% - After deductible Deductible 40% - After deductible Deductible Outpatient doctor services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 020% - After deductible Deductible 40% - After deductible Deductible In a physiciandoctor’s office 0% - After deductible 40% - After deductible Deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered Telemedicine services When rendered by a 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 $25 Not 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 Tests, LabsImaging, Imaging and XLabs (includes machine tests and x-rays - Diagnostic rays) (Diagnostic) Outpatient, /in a physiciandoctor’s office, /urgent care center or free-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* and sleep studies.* 20% - After deductible Deductible 40% - After deductible Sleep studies.* Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Deductible Lab and pathology services. 0% - After deductible 40% - After deductible Deductible Covered Benefits Network Providers You Pay Non-network Providers You Pay See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 020% - After deductible Deductible 40% - After deductible Deductible Lyme disease disease-diagnosis and treatment 020% - After deductible Deductible 40% - After deductibleDeductible

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a 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 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 $15 20% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. $20 Not Covered When rendered by a 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 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 4020% - After deductible Sleep studies.* 0% - After deductible 4020% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 4020% - After deductible Lab and pathology services. 0% - After deductible 4020% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 4020% - After deductible Lyme disease diagnosis and treatment 0% 20% - After deductible 40Urgent Care Urgent care services $50 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. $30 20% - After deductibledeductible Non-routine eye exam $30 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.

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Not Covered Surgery Services* Services Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our a designated telemedicine provider. $25 Not Covered When rendered by a network provider. $25 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine*. 0% - After deductible Not Covered When rendered by a 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 Sleep studies.* 0% - After deductible 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 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 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 0% - After deductible 40% - After deductible $75 Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible $25 Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment $25 Not Covered 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. $0 Not Covered Non-routine eye exam $0 Not Covered 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% - After deductible 40Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductibleNot Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a 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 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 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible 40% - After deductible Not Covered In a physician’s office 020% - After deductible 40Not Covered Respiratory Therapy Inpatient 20% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 20% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 020% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40Not Covered Surgery Services Inpatient physician services 20% - After deductible Surgery Services* Inpatient Not Covered Outpatient physician services 020% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible $35 Not Covered Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $40 Not Covered When rendered by a network provider provider. $40 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine*. 20% - After deductible Not Covered Sleep studies.* 20% - After deductible Not Covered Diagnostic imaging and tests, other than our designated telemedicine the diagnostic imaging services listed above. 20% - After deductible Not Covered Lab and pathology services. 20% - After deductible Not Covered Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 20% - After deductible Not Covered Lyme disease diagnosis and treatment 20% - After deductible Not Covered Urgent Care Urgent care services $75 The level of coverage is the same as network 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 Tests, Labs, Imaging Vision Care Services Vision exam - one routine eye exam per member per plan year. $55 Not Covered Non-routine eye exam $45 Not Covered Pediatric vision care for members under age 19: See Vision Care Services in Section 3 for benefit limits and X-rays details. These services only apply to an enrolled member under the age of 19:. Prescription glasses - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging frame and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. lenses 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - Not Covered Contact lens (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.in lieu of prescription glasses) 0% - After deductible 40% - After deductible Lyme disease diagnosis Not Covered Vision hardware for enrolled members aged 19 and treatment 0% - After deductible 40% - After deductibleolder. 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, pharmacy.

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible 40% - After deductible Not Covered In a physician’s office 010% - After deductible 40Not Covered Respiratory Therapy Inpatient 10% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 10% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 010% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 010% - After deductible 40% - After deductible Not Covered In a physician’s office 010% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 010% - After deductible Not Covered When rendered by a 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 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 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. 010% - After deductible 40Not Covered Sleep studies.* 10% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 010% - After deductible 40% - After deductible Not Covered Lab and pathology services. 010% - After deductible 40% - After deductible Not Covered 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.) 010% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment 010% - After deductible 40% - After deductibleNot Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 4020% - After deductible 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 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a 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 $30 Not 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 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 medicine, and cardiac imaging. 0% - After deductible 4020% - After deductible Sleep studies.* 0% - After deductible 4020% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40$0 20% - After deductible Lab and pathology services. 0% - After deductible 40$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 4020% - After deductible Lyme disease diagnosis and treatment 0$0 20% - After deductible 40Urgent Care Urgent care services $50 The level of coverage is the same as network provider. Vision Care Services Vision exam - one routine eye exam per member per plan year. $0 20% - After deductible Non-routine eye exam $0 20% - After deductible

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 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 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 40% - After deductible Not Covered Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible $75 Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible $25 Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment $25 Not Covered 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. $0 Not Covered Non-routine eye exam $0 Not Covered 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% - After deductible 40Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductibleNot 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, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 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 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 40% - After deductible Not Covered Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible $75 Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible $25 Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment $25 Not Covered Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Routine Vision Exam One routine vision exam per member per plan year $0 Not Covered One routine vision exam when performed to treat members with diabetes. $0 Not Covered Non-routine vision exam $0 Not Covered 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% - After deductible 40Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductibleNot 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, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Not Covered Surgery Services* Services Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $25 Not Covered When rendered by a 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 $25 Not 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 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*, and nuclear medicine and cardiac imagingmedicine*. 0% - After deductible 40% - After deductible Not Covered Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 0% - After deductible 40% - After deductible $75 Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible $25 Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment $25 Not Covered 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. $0 Not Covered Non-routine eye exam $0 Not Covered 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% - After deductible 40Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductibleNot 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, pharmacy.

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible 40% - After deductible Not Covered In a physician’s office 010% - After deductible 40Not Covered Respiratory Therapy Inpatient 10% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 10% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40Not Covered Surgery Services Inpatient physician services 10% - After deductible Surgery Services* Inpatient Not Covered Outpatient physician services 010% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible $30 Not Covered Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $40 Not Covered When rendered by a 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 $40 Not 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 Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-free- standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine and cardiac imagingmedicine*. 010% - After deductible 40Not Covered Sleep studies.* 10% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 010% - After deductible 40% - After deductible Not Covered Lab and pathology services. 010% - After deductible 40% - After deductible Not Covered 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.) 010% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment 010% - After deductible 40Not Covered Urgent Care Urgent care services $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. $70 Not Covered Non-routine eye exam $60 Not Covered Pediatric vision care Services - for members under age 19: See Vision Care 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 10% - After deductibledeductible Not Covered Contact lens (in lieu of prescription glasses) 10% - After deductible 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, pharmacy.

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible 40% - After deductible Not Covered In a physician’s office 010% - After deductible 40Not Covered Respiratory Therapy Inpatient 10% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 10% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 010% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 010% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible $30 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a 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 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay 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. 010% - After deductible 40Not Covered Sleep studies.* 10% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 010% - After deductible 40% - After deductible Not Covered Lab and pathology services. 010% - After deductible 40% - After deductible Not Covered 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.) 010% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment 010% - After deductible 40Not Covered Urgent Care Urgent care services $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. $70 Not Covered Non-routine eye exam $60 Not Covered 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 10% - After deductibledeductible Not Covered Contact lens (in lieu of prescription glasses) 10% - After deductible 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, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible 40% - After deductible Not Covered In a physician’s office 010% - After deductible 40Not Covered Respiratory Therapy Inpatient 10% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 10% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 010% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 010% - After deductible Not Covered When rendered by In a 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 physician’s office $30 Not Covered Benefits - Covered Benefits- See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals 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 the amount you pay Not Covered 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. 010% - After deductible 40Not Covered Sleep studies.* 10% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 010% - After deductible 40% - After deductible Not Covered Lab and pathology services. 010% - After deductible 40% - After deductible Not Covered 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.) 010% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment 010% - After deductible 40Not Covered Urgent Care Urgent care services $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. $70 Not Covered Non-routine eye exam $60 Not Covered 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 10% - After deductibledeductible Not Covered Contact lens (in lieu of prescription glasses) 10% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible 40% - After deductible Not Covered In a physician’s office 020% - After deductible 40Not Covered Respiratory Therapy Inpatient 20% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 20% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 020% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 020% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 020% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 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 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 40Not Covered Sleep studies.* 20% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible $75 Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible $25 Not Covered Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 020% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment $25 Not Covered 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. $0 Not Covered Non-routine eye exam $0 Not Covered 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% - After deductible 40Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductibleNot 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, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Not Covered Surgery Services* Services Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 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 the amount you pay See the covered healthcare service being provided for the amount you pay Not 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 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 40% - After deductible Not Covered Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment 0% - After deductible 40Not Covered Urgent Care Urgent care services 0% - After deductibledeductible The level of coverage is the same as network provider. Vision Care Services 0% - After deductible Vision exam - one routine eye exam per member per plan year. 0% - After deductible Not Covered Non-routine eye exam 0% - After deductible Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible 40% - After deductible Not Covered In a physician’s office 010% - After deductible 40Not Covered Respiratory Therapy Inpatient 10% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 10% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40Not Covered Surgery Services Inpatient physician services 10% - After deductible Surgery Services* Inpatient Not Covered Outpatient physician services 010% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible $30 Not Covered Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $40 Not Covered When rendered by a 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 $40 Not 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 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*, and nuclear medicine and cardiac imagingmedicine*. 010% - After deductible 40Not Covered Sleep studies.* 10% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 010% - After deductible 40% - After deductible Not Covered Lab and pathology services. 010% - After deductible 40% - After deductible Not Covered 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.) 010% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment 010% - After deductible 40Not Covered Urgent Care Urgent care services $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. $70 Not Covered Non-routine eye exam $60 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and Permitted Self-referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Pediatric vision care Services - for members under age 19: See Vision Care 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 10% - After deductibledeductible Not Covered Contact lens (in lieu of prescription glasses) 10% - After deductible 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, pharmacy.

Radiation Therapy/Chemotherapy Services. Outpatient 030% - After deductible 40% - After deductible Not Covered In a physician’s office 030% - After deductible 40Not Covered Respiratory Therapy Inpatient 30% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 30% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 030% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 030% - After deductible 40Not Covered Surgery Services Inpatient physician services 30% - After deductible Surgery Services* Inpatient Not Covered Outpatient physician services 030% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible $45 Not Covered Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $40 Not Covered When rendered by a network provider provider. $40 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine*. 30% - After deductible Not Covered Sleep studies.* 30% - After deductible Not Covered Diagnostic imaging and tests, other than our designated telemedicine providerthe diagnostic imaging services listed above. 30% - After deductible Not Covered Lab and pathology services. 30% - After deductible Not Covered Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See the covered healthcare service being provided Prevention and Early Detection Services for the amount you pay See the covered healthcare service being provided for the amount you pay preventive colorectal services.) 30% - After deductible Not Covered Lyme disease diagnosis and treatment 30% - After deductible 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 Tests, Labs, Imaging Urgent Care Urgent care services $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. $75 Not Covered Non-routine eye exam $65 Not Covered Pediatric vision care for members under age 19: See Vision Care Services in Section 3 for benefit limits and X-rays details. These services only apply to an enrolled member under the age of 19:. Prescription glasses - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging frame and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. lenses 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - Not Covered Contact lens (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.in lieu of prescription glasses) 0% - After deductible 40% - After deductible Lyme disease diagnosis Not Covered Vision hardware for enrolled members aged 19 and treatment 0% - After deductible 40% - After deductibleolder. Not Covered Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 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 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 40% - After deductible Not Covered Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible $75 Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible $25 Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment $25 Not Covered Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Routine Vision Exam One routine vision exam per member per plan year $0 Not Covered One routine vision exam when performed to treat members with diabetes. $0 Not Covered Non-routine vision exam $0 Not Covered 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% - After deductible 40Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductibleNot 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, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 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 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 40% - After deductible Not Covered Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible $75 Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible $25 Not Covered 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 40% - After deductible Not Covered Lyme disease diagnosis and treatment $25 Not Covered 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. $0 Not Covered Non-routine eye exam $0 Not Covered 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% - After deductible 40Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductibleNot 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, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible 40% - After deductible Not Covered In a physician’s office 010% - After deductible 40Not Covered Respiratory Therapy Inpatient 10% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 10% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 010% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 010% - After deductible Not Covered When rendered by In a 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 physician’s office $20 Not Covered Benefits - Covered Benefits- See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals 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. $35 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered 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. 010% - After deductible 40Not Covered Sleep studies.* 10% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 010% - After deductible 40% - After deductible Not Covered Lab and pathology services. 010% - After deductible 40% - After deductible Not Covered 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.) 010% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment 010% - After deductible 40Not Covered Urgent Care Urgent care services $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. $55 Not Covered Non-routine eye exam $45 Not Covered 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 10% - After deductibledeductible Not Covered Contact lens (in lieu of prescription glasses) 10% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible 40% - After deductible Not Covered In a physician’s office 010% - After deductible 40Not Covered Respiratory Therapy Inpatient 10% - After deductible Respiratory Therapy Inpatient 0Not Covered Outpatient 10% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 010% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 010% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 010% - After deductible Not Covered When rendered by In a 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 physician’s office $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals 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 a designated provider. $40 Not Covered When rendered by a network provider. $40 Not Covered 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. 010% - After deductible 40Not Covered Sleep studies.* 10% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 010% - After deductible 40% - After deductible Not Covered Lab and pathology services. 010% - After deductible 40% - After deductible Not Covered 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.) 010% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment 010% - After deductible 40Not Covered Urgent Care Urgent care services $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. $70 Not Covered Non-routine eye exam $60 Not Covered 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 10% - After deductibledeductible Not Covered Contact lens (in lieu of prescription glasses) 10% - After deductible 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, pharmacy.