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? 40% for all other outpatient services including Intensive Behavioral Therapy, Transcranial Magnetic Stimulation, Electroconvulsive Therapy, and Psychological Testing Yes Yes $35 per visit Yes No Morbid Obesity surgery must be received from a Designated Provider. 40% Yes Yes Necessary Medical Supplies 40% Yes Yes Orthotics 40% Yes Yes Pharmaceutical Products which, due to their traits (as determined by us), are administered or directly supervised by a qualified provider or licensed/certified health professional. Note: Benefits for medication normally available by a prescription or order or refill are provided as described under your Outpatient Prescription Drug Section. 40% Yes Yes SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.

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? Inpatient (includes Residential Treatment) 40% for all other outpatient services including Intensive Behavioral Therapy, Transcranial Magnetic Stimulation, Electroconvulsive Therapy, and Psychological Testing Yes Yes Outpatient 40% Office Visit $35 50 per visit Yes Yes Yes No Morbid Obesity surgery must be received from a Designated Provider. 40% Yes Yes Compression garments for treatment of lymphedema are limited to one set upon diagnosis. Benefits are limited to four replacements per Policy year when determined Medically Necessary Medical Supplies and the compression garment cannot be repaired or when required due to a change in your physical condition. 40% Yes Yes Orthotics 40% Yes Yes Pharmaceutical Products which, due to their traits (as determined by us), are administered or directly supervised by a qualified provider or licensed/certified health professional. Note: Benefits for medication normally available by a prescription or order or refill are provided as described under your Outpatient Prescription Drug Section. 40% Yes Yes SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.

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% for Partial Hospitalization Yes Yes 40% for all other outpatient services including Intensive Behavioral Therapy, Transcranial Magnetic Stimulation, Electroconvulsive Therapy, and Psychological Testing Yes Yes $35 40 per visit Yes No Morbid Obesity surgery also known as bariatric surgery must be received from a Designated Provider. 40% Yes Yes Necessary Medical Supplies 40% Yes Yes Orthotics Benefits include orthotic devices for the correction or positional plagiocephaly, including dynamic orthotic cranioplasty (DOC) bands (limited to once per lifetime) and soft helmets. 40% Yes Yes Pharmaceutical Products which, due to their traits (as determined by us), are administered or directly supervised by a qualified provider or licensed/certified health professional. Note: Benefits for medication normally available by a prescription or order or refill are provided as described under your Outpatient Prescription Drug Section. 40% Yes Yes SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.

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? Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Limited per year as follows: • 30 visits for speech therapy. • 30 visits for any combination of physical therapy, occupational therapy and Manipulative Treatment including chiropractic care. Visit limits do not apply for therapies for Covered Persons with a primary diagnosis of autism spectrum disorder. Outpatient 40% for all other outpatient services including Intensive Behavioral Therapy, Transcranial Magnetic Stimulation, Electroconvulsive Therapy, and Psychological Testing Yes Yes $35 Limited to one Hearing Aid per visit Yes No Morbid Obesity surgery must be received from a Designated Providerhearing-impaired ear every 36 months. 40% Yes Yes Necessary Medical Supplies For the administration of intravenous infusion, you must receive services from a provider we identify. 40% Private Duty Nursing 40% Yes Yes Orthotics Yes Yes Hospice Care 40% Yes Yes Pharmaceutical Products which, due to their traits (as determined by us), are administered or directly supervised by a qualified provider or licensed/certified health professional. Note: Benefits for medication normally available by a prescription or order or refill are provided as described under your Outpatient Prescription Drug Section. Hospital - Inpatient Stay 40% Yes Yes Lab Testing - Outpatient $15 per service at a freestanding lab or in a Physician's office Yes No SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.

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? 40% Yes Yes 40% for Intensive Outpatient Program Yes Yes 40% for Partial Hospitalization Yes Yes 40% for all other outpatient services including Intensive Behavioral Therapy, Transcranial Magnetic Stimulation, Electroconvulsive Therapy, and Psychological Testing Yes Yes $35 per visit Yes No Morbid Obesity surgery must be received from a Designated Provider. 40% Yes Yes Necessary Medical Supplies 40% Yes Yes Orthotics Limited to 15 devices per Covered Person per calendar year 40% Yes Yes Pharmaceutical Products which, due to their traits (as determined by us), are administered or directly supervised by a qualified provider or licensed/certified health professional. Note: Benefits for medication normally available by a prescription or order or refill are provided as described under your Outpatient Prescription Drug Section. 40% Yes Yes SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.