Common use of Radiation Therapy/Chemotherapy Services Clause in Contracts

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible $40 Not Covered Surgery Services* Inpatient physician services 0% - After deductible Not Covered Outpatient Physician services - includes physician services and received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility servicesfacility. 0% Standard $750 - After deductible Not Covered In a physician’s office 0% - After deductible Enhanced $375 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible $40 Not Covered Surgery Services* Inpatient physician services 0% - After deductible Not Covered Outpatient Physician services - includes physician services and received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility servicesfacility. 0% Standard $750 - After deductible Not Covered In a physician’s office 0% - After deductible Enhanced $375 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible $15 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Surgery Services* Services Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible Not Covered In a physician’s office 020% - After deductible Not Covered Respiratory Therapy Inpatient 020% - After deductible Not Covered Outpatient 020% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 020% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* Inpatient physician services 020% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 020% - After deductible Not Covered In a physician’s office 0% - After deductible $25 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible Not Covered In a physician’s office 020% - After deductible Not Covered Respiratory Therapy Inpatient 020% - After deductible Not Covered Outpatient 020% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 020% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* Inpatient physician services 020% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 020% - After deductible Not Covered In a physician’s office 0% - 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible $45 Not Covered Surgery Services* Inpatient physician services 0% - After deductible Not Covered Outpatient Physician services - includes physician services and received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility servicesfacility. 0% Standard $1,000 - After deductible Not Covered In a physician’s office 0% - After deductible Enhanced $500 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Surgery Services* Services Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office office. 0% - 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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $10 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 Not CoveredSee the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* Services Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office office. 0% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $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 Not Covered