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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $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. $30 Not Covered Services connected to dental care when performed in an outpatient facility * 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 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% 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 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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 30 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 50 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 50 Not Covered Services connected to dental care when performed in an outpatient facility * 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 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% 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 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 $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 $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 $20 Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 45 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 45 Not Covered Services connected to dental care when performed in an outpatient facility * 0% Standard $1,000 - 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 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% 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 Not CoveredCovered 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 Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - 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 Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - 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% The level of coverage is the same as network provider. Asthma management 0% Not Covered Hospital emergency room $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 Not Covered 20% - 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 Not Covered 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered 30 20% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 Not Covered 30 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered 20% - After deductible In a physician's office - limited to 12 visits per plan year. $30 Not Covered 45 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 Not Covered 40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - 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% Not Covered 0% X-rays 0% Not Covered 0% Cleanings (prophylaxis) 0% Not Covered 0% Fluoride treatments 0% Not Covered 0% Sealants 0% Not Covered 0% Space Maintainers 0% Not Covered 0% Palliative treatment 50% Not Covered 50% Fillings 50% Not Covered 50% Simple extractions 50% Not Covered 50% Denture repairs and relines/rebasing 50% Not Covered 50% Crowns & onlays 50% Not Covered 50% Therapeutic Pulpotomies 50% Not Covered 50% Root canal therapy 50% Not Covered 50% Non-surgical periodontal services 50% Not Covered 50% Surgical periodontal services 50% Not Covered 50% Periodontal maintenance 50% Not Covered 50% Fixed bridges and dentures 50% Not Covered 50% Implants 50% Not Covered 50% Oral surgery services 50% Not Covered 50% General anesthesia or IV sedation - dental office 50% Not Covered 50% Biopsies 50% Not Covered 50% Occlusal (night) guards 50% Not Covered 50% Orthodontic services (braces) - when medically necessary. 50% Not Covered 50% Inpatient/outpatient/in your home 0% - After deductible Not Covered20% - After 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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 10 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 10 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 25 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 100 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. $30 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - 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 Dental Care (Pediatric) - for members under age 19 See Dental Services connected to dental care when performed in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations outpatient facility * 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% 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. 010% - 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 010% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 35 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 35 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 010% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 45 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 10% - 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. $30 Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible Not Covered Covered Benefits- See Covered Healthcare Services 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 Dental Care (Pediatric) Services connected to dental care when performed in an outpatient facility * 10% - 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. 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 010% - After deductible Not CoveredCovered Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 10% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 10% - 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. 10% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 10% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 10% - After deductible Not Covered Enteral formula or food taken orally * 10% - 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. 10% - 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 Not Covered 50% - 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 Not Covered 50% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 50% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered 40 50% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 Not Covered 40 50% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 030% - After deductible Not Covered 50% - After deductible In a physician's office - limited to 12 visits per plan year. $30 Not Covered 45 50% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. $150 250 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. $30 Not Covered 50 50% - After deductible Services connected to dental care when performed in an outpatient facility * 030% - After deductible Not Covered 50% - 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% Not Covered 0% X-rays 0% Not Covered 0% Cleanings (prophylaxis) 0% Not Covered 0% Fluoride treatments 0% Not Covered 0% Sealants 0% Not Covered 0% Space Maintainers 0% Not Covered 0% Palliative treatment 50% Not Covered 50% Fillings 50% Not Covered 50% Simple extractions 50% Not Covered 50% Denture repairs and relines/rebasing 50% Not Covered 50% Crowns & onlays 50% Not Covered 50% Therapeutic Pulpotomies 50% Not Covered 50% Root canal therapy 50% Not Covered 50% Non-surgical periodontal services 50% Not Covered 50% Surgical periodontal services 50% Not Covered 50% Periodontal maintenance 50% Not Covered 50% Fixed bridges and dentures 50% Not Covered 50% Implants 50% Not Covered 50% Oral surgery services 50% Not Covered 50% General anesthesia or IV sedation - dental office 50% Not Covered 50% Biopsies 50% Not Covered 50% Occlusal (night) guards 50% Not Covered 50% Orthodontic services (braces) - when medically necessary. 50% Not Covered 50% Inpatient/outpatient/in your home 030% - After deductible Not Covered50% - After 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 $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 $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 $20 Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 45 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 45 Not Covered Services connected to dental care when performed in an outpatient facility * 0% Standard $1,000 - 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 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% 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 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. 020% - After deductible Not Covered 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 Not Covered 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 40% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered 40 40% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 Not Covered 40 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 020% - After deductible Not Covered 40% - After deductible In a physician's office - limited to 12 visits per plan year. $30 Not Covered 40 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. $150 250 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. $30 Not Covered 50 40% - After deductible Services connected to dental care when performed in an outpatient facility * 020% - After deductible Not Covered 40% - 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% Not Covered 0% X-rays 0% Not Covered 0% Cleanings (prophylaxis) 0% Not Covered 0% Fluoride treatments 0% Not Covered 0% Sealants 0% Not Covered 0% Space Maintainers 0% Not Covered 0% Palliative treatment 50% Not Covered 50% Fillings 50% Not Covered 50% Simple extractions 50% Not Covered 50% Denture repairs and relines/rebasing 50% Not Covered 50% Crowns & onlays 50% Not Covered 50% Therapeutic Pulpotomies 50% Not Covered 50% Root canal therapy 50% Not Covered 50% Non-surgical periodontal services 50% Not Covered 50% Surgical periodontal services 50% Not Covered 50% Periodontal maintenance 50% Not Covered 50% Fixed bridges and dentures 50% Not Covered 50% Implants 50% Not Covered 50% Oral surgery services 50% Not Covered 50% General anesthesia or IV sedation - dental office 50% Not Covered 50% Biopsies 50% Not Covered 50% Occlusal (night) guards 50% Not Covered 50% Orthodontic services (braces) - when medically necessary. 50% Not Covered 50% Inpatient/outpatient/in your home 020% - After deductible Not Covered40% - After 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 Not Covered 20% - 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 Not Covered 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered 20% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered 30 20% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 Not Covered 30 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered 20% - After deductible In a physician's office - limited to 12 visits per plan year. $30 Not Covered 50 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 Not Covered 50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - 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% Not Covered 0% X-rays 0% Not Covered 0% Cleanings (prophylaxis) 0% Not Covered 0% Fluoride treatments 0% Not Covered 0% Sealants 0% Not Covered 0% Space Maintainers 0% Not Covered 0% Palliative treatment 50% Not Covered 50% Fillings 50% Not Covered 50% Simple extractions 50% Not Covered 50% Denture repairs and relines/rebasing 50% Not Covered 50% Crowns & onlays 50% Not Covered 50% Therapeutic Pulpotomies 50% Not Covered 50% Root canal therapy 50% Not Covered 50% Non-surgical periodontal services 50% Not Covered 50% Surgical periodontal services 50% Not Covered 50% Periodontal maintenance 50% Not Covered 50% Fixed bridges and dentures 50% Not Covered 50% Implants 50% Not Covered 50% Oral surgery services 50% Not Covered 50% General anesthesia or IV sedation - dental office 50% Not Covered 50% Biopsies 50% Not Covered 50% Occlusal (night) guards 50% Not Covered 50% Orthodontic services (braces) - when medically necessary. 50% Not Covered 50% Inpatient/outpatient/in your home 0% - After deductible Not Covered20% - After 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 Not Covered 20% - 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 Not Covered 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered 40 20% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 Not Covered 40 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered 20% - After deductible In a physician's office - limited to 12 visits per plan year. $30 Not Covered 45 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. $150 300 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. $30 Not Covered 50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - 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% Not Covered 0% X-rays 0% Not Covered 0% Cleanings (prophylaxis) 0% Not Covered 0% Fluoride treatments 0% Not Covered 0% Sealants 0% Not Covered 0% Space Maintainers 0% Not Covered 0% Palliative treatment 50% Not Covered 50% Fillings 50% Not Covered 50% Simple extractions 50% Not Covered 50% Denture repairs and relines/rebasing 50% Not Covered 50% Crowns & onlays 50% Not Covered 50% Therapeutic Pulpotomies 50% Not Covered 50% Root canal therapy 50% Not Covered 50% Non-surgical periodontal services 50% Not Covered 50% Surgical periodontal services 50% Not Covered 50% Periodontal maintenance 50% Not Covered 50% Fixed bridges and dentures 50% Not Covered 50% Implants 50% Not Covered 50% Oral surgery services 50% Not Covered 50% General anesthesia or IV sedation - dental office 50% Not Covered 50% Biopsies 50% Not Covered 50% Occlusal (night) guards 50% Not Covered 50% Orthodontic services (braces) - when medically necessary. 50% Not Covered 50% Inpatient/outpatient/in your home 0% - After deductible Not Covered20% - After 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 Not Covered 20% - 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 Not Covered 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered 30 20% - After deductible Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 Not Covered 30 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered 20% - After deductible In a physician's office - limited to 12 visits per plan year. $30 Not Covered 40 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 Not Covered 40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - 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% Not Covered 0% X-rays 0% Not Covered 0% Cleanings (prophylaxis) 0% Not Covered 0% Fluoride treatments 0% Not Covered 0% Sealants 0% Not Covered 0% Space Maintainers 0% Not Covered 0% Palliative treatment 50% Not Covered 50% Fillings 50% Not Covered 50% Simple extractions 50% Not Covered 50% Denture repairs and relines/rebasing 50% Not Covered 50% Crowns & onlays 50% Not Covered 50% Therapeutic Pulpotomies 50% Not Covered 50% Root canal therapy 50% Not Covered 50% Non-surgical periodontal services 50% Not Covered 50% Surgical periodontal services 50% Not Covered 50% Periodontal maintenance 50% Not Covered 50% Fixed bridges and dentures 50% Not Covered 50% Implants 50% Not Covered 50% Oral surgery services 50% Not Covered 50% General anesthesia or IV sedation - dental office 50% Not Covered 50% Biopsies 50% Not Covered 50% Occlusal (night) guards 50% Not Covered 50% Orthodontic services (braces) - when medically necessary. 50% Not Covered 50% Inpatient/outpatient/in your home 0% - After deductible Not Covered20% - After 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 $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 $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 $15 Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 15 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 15 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 40 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $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. $30 40 Not Covered Services connected to dental care when performed in an outpatient facility * 0% Standard $750 - 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 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% 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 Not CoveredCovered 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 Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - 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 Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - 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% The level of coverage is the same as network provider. Asthma management 0% Not Covered Hospital emergency room $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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 010% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 30 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 010% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 45 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 10% - 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. $30 Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible Not Covered Covered Benefits- See Covered Healthcare Services 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 Dental Care (Pediatric) Services connected to dental care when performed in an outpatient facility * 10% - 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. 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 010% - After deductible Not CoveredCovered Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 10% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 10% - 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. 10% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 10% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 10% - After deductible Not Covered Enteral formula or food taken orally * 10% - 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. 10% - 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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 15 - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 15 - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 25 - After deductible Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 100 - 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. $30 Not Covered Services connected to dental care when performed in an outpatient facility * 0% 25 - After deductible Not Covered (*) 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 connected to dental care when performed in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations outpatient facility * 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% After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible Not CoveredCovered 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 Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - 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 Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - 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.

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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $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. $30 Not Covered 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 (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care Durable Medical Equipment (Pediatric) DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - for members under age 19 See Dental Services in Section 3 for benefit limits and detailsMust be provided by a licensed medical supply provider. These services only apply to an enrolled member under the age of 19. 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% 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 020% - After deductible Not CoveredCovered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - 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 Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - 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% The level of coverage is the same as network provider. Asthma management 0% Not Covered Hospital emergency room $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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 25 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 25 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 40 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 40 Not Covered 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 (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) Outpatient durable medical equipment* - for members under age 19 See Dental Services in Section 3 for benefit limits and detailsMust be provided by a licensed medical supply provider. These services only apply to an enrolled member under the age of 19. 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% 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 020% - After deductible Not CoveredCovered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - 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 Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - 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% The level of coverage is the same as network provider. Asthma management 0% Not Covered Hospital emergency room $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 $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 $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 $15 Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 15 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $20 15 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 40 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $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. $30 40 Not Covered Services connected to dental care when performed in an outpatient facility * 0% Standard $750 - 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 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% 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 Not CoveredCovered 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 Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - 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 Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - 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% The level of coverage is the same as network provider. Asthma management 0% Not Covered Hospital emergency room $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 Not Covered 20% - 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 Not Covered 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered 20% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered 25 20% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 Not Covered 25 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered 20% - After deductible In a physician's office - limited to 12 visits per plan year. $30 Not Covered 40 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 Not Covered 40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - 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% Not Covered 0% X-rays 0% Not Covered 0% Cleanings (prophylaxis) 0% Not Covered 0% Fluoride treatments 0% Not Covered 0% Sealants 0% Not Covered 0% Space Maintainers 0% Not Covered 0% Palliative treatment 50% Not Covered 50% Fillings 50% Not Covered 50% Simple extractions 50% Not Covered 50% Denture repairs and relines/rebasing 50% Not Covered 50% Crowns & onlays 50% Not Covered 50% Therapeutic Pulpotomies 50% Not Covered 50% Root canal therapy 50% Not Covered 50% Non-surgical periodontal services 50% Not Covered 50% Surgical periodontal services 50% Not Covered 50% Periodontal maintenance 50% Not Covered 50% Fixed bridges and dentures 50% Not Covered 50% Implants 50% Not Covered 50% Oral surgery services 50% Not Covered 50% General anesthesia or IV sedation - dental office 50% Not Covered 50% Biopsies 50% Not Covered 50% Occlusal (night) guards 50% Not Covered 50% Orthodontic services (braces) - when medically necessary. 50% Not Covered 50% Inpatient/outpatient/in your home 0% - After deductible Not Covered20% - 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% 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% 20% - After deductible Hospital emergency room $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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 0% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 0% - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 0% - After deductible Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 The level of coverage is the same as network provider. 0% - After deductible Not Covered In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $30 0% - After deductible Not Covered 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 (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care Durable Medical Equipment (PediatricDME), 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 Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - 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 Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - 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 under age 19 See Dental Services in Section 3 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 Not Covered Hospital emergency room 0% - After deductible 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 benefit limits and details. These services only apply to an enrolled a member under 21; the age benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of 19coverage is the same as network provider. Oral evaluations Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered X-rays Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Cleanings (prophylaxis) Human leukocyte antigen testing 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% 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 Not Covered 20% - 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 Not Covered 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered 20% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 Not Covered 20% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 Not Covered 20% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered 20% - After deductible In a physician's office - limited to 12 visits per plan year. $30 Not Covered 20% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. $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. $30 Not Covered 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - 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% Not Covered 0% X-rays 0% Not Covered 0% Cleanings (prophylaxis) 0% Not Covered 0% Fluoride treatments 0% Not Covered 0% Sealants 0% Not Covered 0% Space Maintainers 0% Not Covered 0% Palliative treatment 50% Not Covered 50% Fillings 50% Not Covered 50% Simple extractions 50% Not Covered 50% Denture repairs and relines/rebasing 50% Not Covered 50% Crowns & onlays 50% Not Covered 50% Therapeutic Pulpotomies 50% Not Covered 50% Root canal therapy 50% Not Covered 50% Non-surgical periodontal services 50% Not Covered 50% Surgical periodontal services 50% Not Covered 50% Periodontal maintenance 50% Not Covered 50% Fixed bridges and dentures 50% Not Covered 50% Implants 50% Not Covered 50% Oral surgery services 50% Not Covered 50% General anesthesia or IV sedation - dental office 50% Not Covered 50% Biopsies 50% Not Covered 50% Occlusal (night) guards 50% Not Covered 50% Orthodontic services (braces) - when medically necessary. 50% Not Covered 50% Inpatient/outpatient/in your home 0% - After deductible Not Covered20% - 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% 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% 20% - After deductible Hospital emergency room $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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 25 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 25 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 40 Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 40 Not Covered Services connected to dental care when performed in an outpatient facility * 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 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% 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 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 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $20 0% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $20 0% - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible Not Covered In a physician's office - limited to 12 visits per plan year. $30 0% - After deductible Not Covered Emergency room - When services are due to accidental injury to sound natural teeth. $150 The level of coverage is the same as network provider. 0% - After deductible Not Covered In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $30 0% - After deductible Not Covered 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 (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (Pediatricother than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - 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 under age 19 See Dental Services in Section 3 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 Not Covered Hospital emergency room 0% - After deductible 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 benefit limits and details. These services only apply to an enrolled a member under 21; the age benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of 19coverage is the same as network provider. Oral evaluations Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered X-rays Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Cleanings (prophylaxis) Human leukocyte antigen testing 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% 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