Common use of Covered Health Care Service Clause in Contracts

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Habilitative Services Home Health Care Hospice Care Lab, X-Ray and Diagnostics - Outpatient

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-Co- payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance Dollar Amount or BothPercentage. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? None Yes Yes Outpatient None for Partial Hospitalization/Intensiv e Outpatient Treatment/Intensive Behavioral Therapy Office Visit None Yes Yes Yes Yes

Covered Health Care Service. What Is the Co- Co-payment or Co- Co-insurance You Pay? This May Include a Co-payment, Co- Co-insurance or Both. Does the Amount You Pay Apply to the Out-of-of- Pocket Limit? Does the Annual Deductible Apply?

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Enteral Nutrition

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? 40% Yes Yes Dental Services - Accident Only 40% Yes Yes

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Rehabilitation Services - Outpatient Therapy Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co- payment, Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Lab, X-Ray and Diagnostics - Outpatient

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Urgent Care Center Services Virtual Care Services

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Physician Fees for Surgical and Medical Services Physician's Office Services - Sickness and Injury

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co- payment, Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Hearing Aids Home Health Care

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-Co- payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? 50% for services provided by any other Network Physician Yes Yes

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-Co- payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Allowed Amounts For Network Benefits, Allowed Amounts are based on the following: When Covered Health Care Services are received from an out-of-Network provider as described below, Allowed Amounts are determined as follows:

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Lab, X-Ray and Diagnostics - Outpatient

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Allowed Amounts For Network Benefits, Allowed Amounts are based on the following: When Covered Health Care Services are received from an out-of-Network provider as described below, Allowed Amounts are determined as follows:

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-Co- payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? 50% Yes Yes

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Diabetes Services

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Ambulance Services

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co- payment, Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Emergency Health Care Services - Outpatient Habilitative Services

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Transplantation Services

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Clinical Trials Diabetes Services

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? None Yes Yes

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co- payment, Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?

Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co- payment, Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?? Diabetes Services