Common use of Behavioral Health Services – Mental Health and Substance Use Disorder Clause in Contracts

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. Oral evaluations 0% - After deductible The level of coverage is the same as network provider0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. Asthma management 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $20 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $30 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $30 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesOral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% Not Covered Fillings 50% Not Covered Simple extractions 50% Not Covered Denture repairs and relines/rebasing 50% Not Covered Crowns & onlays 50% Not Covered Therapeutic Pulpotomies 50% Not Covered Root canal therapy 50% Not Covered Non-surgical periodontal services 50% Not Covered Surgical periodontal services 50% Not Covered Periodontal maintenance 50% Not Covered Fixed bridges and dentures 50% Not Covered Implants 50% Not Covered Oral surgery services 50% Not Covered General anesthesia or IV sedation - dental office 50% Not Covered Biopsies 50% Not Covered Occlusal (night) guards 50% Not Covered Orthodontic services (braces) - when medically necessary. 50% Not Covered Inpatient/outpatient/in your home 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $30 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $50 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $50 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesOral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% Not Covered Fillings 50% Not Covered Simple extractions 50% Not Covered Denture repairs and relines/rebasing 50% Not Covered Crowns & onlays 50% Not Covered Therapeutic Pulpotomies 50% Not Covered Root canal therapy 50% Not Covered Non-surgical periodontal services 50% Not Covered Surgical periodontal services 50% Not Covered Periodontal maintenance 50% Not Covered Fixed bridges and dentures 50% Not Covered Implants 50% Not Covered Oral surgery services 50% Not Covered General anesthesia or IV sedation - dental office 50% Not Covered Biopsies 50% Not Covered Occlusal (night) guards 50% Not Covered Orthodontic services (braces) - when medically necessary. 50% Not Covered Inpatient/outpatient/in your home 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. Not Covered In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. Oral evaluations 0% - After deductible The level of coverage is the same as network provider. Asthma management Not Covered X-rays 0% - After deductible 40% - After deductible Hospital emergency room Not Covered Cleanings (prophylaxis) 0% - After deductible The level of coverage is the same as network provider.Not Covered Fluoride treatments 0% - After deductible Not Covered Sealants 0% - After deductible Not Covered Space Maintainers 0% - After deductible Not Covered Palliative treatment 50% - After deductible Not Covered Fillings 50% - After deductible Not Covered Simple extractions 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible Not Covered Crowns & onlays 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible Not Covered Root canal therapy 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible Not Covered Implants 50% - After deductible Not Covered Oral surgery services 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible Not Covered Biopsies 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$20 20% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40$20 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$30 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$30 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 4020% - After deductible Hospital emergency room 0% - After deductible $150 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $30 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $50 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $50 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Not Covered Hospital emergency room 0% - After deductible $200 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$30 20% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40$30 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$50 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 4020% - After deductible Hospital emergency room 0% - After deductible $200 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 010% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 010% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 010% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $35 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40% - After deductible $35 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 010% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $45 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Covered Benefits- See Covered Healthcare Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible for additionalbenefit limitsand 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 Services connected to dental care when performed in an outpatient facility * 10% - After deductible Not Covered Oral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% - After deductible Not Covered Fillings 50% - After deductible Not Covered Simple extractions 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible Not Covered Crowns & onlays 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible Not Covered Root canal therapy 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible Not Covered Implants 50% - After deductible Not Covered Oral surgery services 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible Not Covered Biopsies 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible Not Covered Inpatient/outpatient/in your home 10% - After deductible Not Covered Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 2010% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2010% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 2010% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 010% - After deductible The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 030% - After deductible 4050% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 030% - After deductible 4050% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4050% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$40 50% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40$40 50% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 030% - After deductible 4050% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$45 50% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $250 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 50% - After deductible Services connected to dental care when performed in an outpatient facility * 030% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4050% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* Dental Care (Pediatric) - Must be provided by a licensed medical supply providerfor members under age 19 See Dental Services in Section 3 for benefit limits and details. 20These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 30% - After deductible 4050% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$40 20% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40$40 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$45 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $300 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesOral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible The level of coverage is the same as network provider. Asthma management 020% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$15 20% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40$15 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$25 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$25 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 4020% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 4020% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Asthma management $25 20% - After deductible Hospital emergency room $100 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $25 20% - After deductible Hearing diagnostic testing 0% 20% - After deductible Hearing aids - The benefit limit is $1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Asthma management Intermittent skilled services when billed by a home health care agency. 0% - After deductible 4020% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $20 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $30 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $30 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Not Covered Hospital emergency room 0% - After deductible $150 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$30 20% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40$30 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$45 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesOral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible The level of coverage is the same as network provider. Asthma management 020% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible $1,000 Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible $20 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible $20 Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $20 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $45 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $45 Not Covered Services connected to dental care when performed in an outpatient facility * 0% Standard $1,000 - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Enhanced $500 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Not Covered Hospital emergency room 0% - After deductible $200 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. Not Covered In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40Not Covered Hospital emergency room 0% - After deductible Hospital emergency room Not Covered Coverage varies based on type of service. Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21; the benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of coverage is the same as network provider.. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% - After deductible Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 0% - After deductible Not Covered Outpatient - facility 0% - After deductible Not Covered In the physician’s office/in your home 0% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible Not Covered In a hospital or other health care facility 0% - After deductible Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible 40% - After deductible Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$20 20% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40$20 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$30 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$30 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% - After deductible 4020% - After deductible Hospital emergency room 0% - After deductible $150 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 010% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 010% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 010% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $30 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40% - After deductible $30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 010% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $45 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Covered Benefits- See Covered Healthcare Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible for additionalbenefit limitsand 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 Services connected to dental care when performed in an outpatient facility * 10% - After deductible Not Covered Oral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% - After deductible Not Covered Fillings 50% - After deductible Not Covered Simple extractions 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible Not Covered Crowns & onlays 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible Not Covered Root canal therapy 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible Not Covered Implants 50% - After deductible Not Covered Oral surgery services 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible Not Covered Biopsies 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible Not Covered Inpatient/outpatient/in your home 10% - After deductible Not Covered Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 2010% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2010% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 2010% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 010% - After deductible The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible 40% - After deductible Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 020% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 020% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible $40 40% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible $40 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 020% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible $40 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $250 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible $50 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 020% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* Dental Care (Pediatric) - Must be provided by a licensed medical supply providerfor members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$30 20% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40$30 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$50 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesOral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible The level of coverage is the same as network provider. Asthma management 020% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible $1,000 Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible $20 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible $20 Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $20 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $45 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $45 Not Covered Services connected to dental care when performed in an outpatient facility * 0% Standard $1,000 - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Enhanced $500 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesOral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% Not Covered Fillings 50% Not Covered Simple extractions 50% Not Covered Denture repairs and relines/rebasing 50% Not Covered Crowns & onlays 50% Not Covered Therapeutic Pulpotomies 50% Not Covered Root canal therapy 50% Not Covered Non-surgical periodontal services 50% Not Covered Surgical periodontal services 50% Not Covered Periodontal maintenance 50% Not Covered Fixed bridges and dentures 50% Not Covered Implants 50% Not Covered Oral surgery services 50% Not Covered General anesthesia or IV sedation - dental office 50% Not Covered Biopsies 50% Not Covered Occlusal (night) guards 50% Not Covered Orthodontic services (braces) - when medically necessary. 50% Not Covered Inpatient/outpatient/in your home 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in performedin an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* Dental Care (Pediatric) - Must be provided by a licensed medical supply providerfor members under age 19 See Dental Services in Section 3 for benefit limits and details. 20These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 400% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20X-rays 0% - After deductible 400% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Cleanings (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20prophylaxis) 0% - After deductible 400% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20Fluoride treatments 0% - After deductible 400% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20Sealants 0% - After deductible 400% - After deductible Enteral formula or food taken orally * 20Space Maintainers 0% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesPalliative treatment 0% - After deductible 50% - After deductible Fillings 0% - After deductible 50% - After deductible Simple extractions 0% - After deductible 50% - After deductible Denture repairs and relines/rebasing 0% - After deductible 50% - After deductible Crowns & onlays 0% - After deductible 50% - After deductible Therapeutic Pulpotomies 0% - After deductible 50% - After deductible Root canal therapy 0% - After deductible 50% - After deductible Non-surgical periodontal services 0% - After deductible 50% - After deductible Surgical periodontal services 0% - After deductible 50% - After deductible Periodontal maintenance 0% - After deductible 50% - After deductible Fixed bridges and dentures 0% - After deductible 50% - After deductible Implants 0% - After deductible 50% - After deductible Oral surgery services 0% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 0% - After deductible 50% - After deductible Biopsies 0% - After deductible 50% - After deductible Occlusal (night) guards 0% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 0% - After deductible The level of coverage is the same as network provider. Asthma management 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% $15 - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% $15 - After deductible 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% $40 - After deductible 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% $200 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% $200 - After deductible The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible $750 Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible $15 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible $15 Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $15 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40% - After deductible $15 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $40 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Services connected to dental care when performed in an outpatient facility * 0% Standard $750 - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Enhanced $375 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Not Covered Hospital emergency room 0% - After deductible $150 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% $15 - After deductible 40% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% $15 - After deductible 40% - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% $25 - After deductible 40% - After deductible Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% $100 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% $25 - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $10 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40% - After deductible $10 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $25 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible $25 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipmentServices connected to dental care when performed in an outpatient facility * - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$30 20% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. 0% - After deductible 40$30 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$40 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesOral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible The level of coverage is the same as network provider. Asthma management 020% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $25 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $25 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $40 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Not Covered Hospital emergency room 0% - After deductible $200 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 4020% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 4020% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40$25 20% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40$25 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 4020% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40$40 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% - After deductible 4020% - After deductible Hospital emergency room 0% - After deductible $200 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible $750 Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible $15 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible $15 Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $15 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $15 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $40 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Services connected to dental care when performed in an outpatient facility * 0% Standard $750 - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Enhanced $375 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Not Covered Hospital emergency room 0% - After deductible $150 The level of coverage is the same as network provider.

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible $25 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible $25 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible $40 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider Dental Care (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigsPediatric) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to 36 monthsan enrolled member under the age of 19. The provider must be certified as an EIS provider by the Rhode Island Department of Human ServicesOral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% Not Covered Fillings 50% Not Covered Simple extractions 50% Not Covered Denture repairs and relines/rebasing 50% Not Covered Crowns & onlays 50% Not Covered Therapeutic Pulpotomies 50% Not Covered Root canal therapy 50% Not Covered Non-surgical periodontal services 50% Not Covered Surgical periodontal services 50% Not Covered Periodontal maintenance 50% Not Covered Fixed bridges and dentures 50% Not Covered Implants 50% Not Covered Oral surgery services 50% Not Covered General anesthesia or IV sedation - dental office 50% Not Covered Biopsies 50% Not Covered Occlusal (night) guards 50% Not Covered Orthodontic services (braces) - when medically necessary. 50% Not Covered Inpatient/outpatient/in your home 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. Not Covered In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40Not Covered Hospital emergency room 0% - After deductible Hospital emergency room Not Covered Coverage varies based on type of service. Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21; the benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of coverage is the same as network provider.. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% - After deductible Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 0% - After deductible Not Covered Outpatient - facility 0% - After deductible Not Covered In the physician’s office/in your home 0% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible Not Covered In a hospital or other health care facility 0% - After deductible Not Covered