Common use of Dental Services - Accidental Injury (Emergency Clause in Contracts

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Services connected to dental care when performed in an outpatient facility * 10% - After deductible Not Covered 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible $45 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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 * 20% - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 020% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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. Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing exam $45 Not Covered Hearing diagnostic testing 20% - After deductible Not Covered Hearing aids - The benefit limit is $1,500 per hearing aid. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 20% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 20% - After deductible Not Covered Human leukocyte antigen testing 20% - 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. 20% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 2010% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2010% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 2010% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 2010% - After deductible The level of coverage is the same as network provider.. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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 10% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% $200 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 500% - After deductible 50% - After deductible Fillings 500% - After deductible 50% - After deductible Simple extractions 500% - After deductible 50% - After deductible Denture repairs and relines/rebasing 500% - After deductible 50% - After deductible Crowns & onlays 500% - After deductible 50% - After deductible Therapeutic Pulpotomies 500% - After deductible 50% - After deductible Root canal therapy 500% - After deductible 50% - After deductible Non-surgical periodontal services 500% - After deductible 50% - After deductible Surgical periodontal services 500% - After deductible 50% - After deductible Periodontal maintenance 500% - After deductible 50% - After deductible Fixed bridges and dentures 500% - After deductible 50% - After deductible Implants 500% - After deductible 50% - After deductible Oral surgery services 500% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 500% - After deductible 50% - After deductible Biopsies 500% - After deductible 50% - After deductible Occlusal (night) guards 500% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 500% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible 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. 200% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible 40% - After deductible Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% $300 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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 * 0% - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider.. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. Not Covered In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $150 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible 40% - After deductible teet.h $30 20%- Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility * 0% - After deductible 40% - After deductible 0%- Afterdeductible 20%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0%- Afterdeductible 20%- Afterdeductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatientdurable medical equipmen-t*Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplies-*Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supplpyrovider(other than apharmacy). See the Summary of Pharmacy Benefits for supplies purchased at apharmacy. 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20%- Afterdeductible 40%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers NetworkProviders 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider.xxxxxx.xx Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Asthma management 0% 20%- Afterdeductible Emergency Room Services Hospitalemergencyroom $150 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam $30 20%- Afterdeductible Hearing diagnostic testing 0% 20%- Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for amemberunder 19; thebenefit limis $700 per hearing aid for amember19 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Intermittent skilled services when billed by a home hea care agency. 0%- Afterdeductible 20%- Afterdeductible Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Services Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) D infertility treatment cycles will be coveredplpaenryear with a total of eight (8) infertility treatcmyecnlets covered in a P H liPfetimEe. H U ¶ V 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 20%- Afterdeductible General hospitaol r specialty hospitaslervices*- unlimited days 0%- Afterdeductible 20%- Afterdeductible Rehabilitationfacility services-*limited to45 days perplan year. 0%- Afterdeductible 20%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 20%- Afterdeductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. $100 $100** In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0$25 20% - After deductible 40% plus $25 - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 5020% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible 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 4020% - After deductible deductible** Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible deductible** Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 4020% - After deductible deductible** Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible deductible** Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 4020% - After deductible deductible** Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. 20% - After deductible** 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.20% - After deductible**

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. $150 $150 In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 5020% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible 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 4020% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 4020% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Flex Plan (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. 20% - After deductible 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.20% - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Services connected to dental care when performed in an outpatient facility * 10% - After deductible Not Covered 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible Not Covered Therapeutic pulpotomies 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible Not Covered Palliative treatment 0% - After deductible Palliative treatment 50Not Covered Fillings 0% - After deductible 50Not Covered Simple extractions 0% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 500% - After deductible 50Not Covered Crowns & onlays 0% - After deductible Crowns & onlays 50Not Covered Therapeutic Pulpotomies 0% - After deductible 50Not Covered Root canal therapy 0% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 500% - After deductible 50Not Covered Surgical periodontal services 0% - After deductible Surgical periodontal services 50Not Covered Periodontal maintenance 0% - After deductible 50Not Covered Fixed bridges and dentures 0% - After deductible Periodontal maintenance 50Not Covered Implants 0% - After deductible 50Not Covered Oral surgery services 0% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 500% - After deductible 50Not Covered Biopsies 0% - After deductible Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 500% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 500% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible 40% - After deductible teet.h 0%- Afterdeductible 40%- Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility* 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Dialysis Services Inpatient/outpatie/nint yourhome 0%- Afterdeductible 40%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - 0%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic 0%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - 0%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatmenttreatmnet. 20% - After deductible 0%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Asthma management 0%- Afterdeductible 40%- Afterdeductible Emergency Room Services Hospitalemergencyroom 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam 0%- Afterdeductible 40%- Afterdeductible Hearing diagnostic testing 0%- Afterdeductible 40%- Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for a member under 19; thbeenefit limis $700 per hearing aid for a member 19 and older. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Intermittent skilled services when billed by a home hea care agency. 0%- Afterdeductible 40%- Afterdeductible Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 40%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0%- Afterdeductible 40%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) -ivnitDro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in a P H liPfetimEe. H U ¶ V 0%- Afterdeductible 40%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 40%- Afterdeductible General hospitaol r specialtyhospitalservices*- unlimited days 0%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility service*s- limited to 45 days peprlan year. 0%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 40%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for details. 0%- After deductible 40%- Afterdeductible Surgery services- includes mastectomy and reconstructi surgery. See Mastectomy Services in Section 3 for deta 0%- After deductible 40%- Afterdeductible Mastectom-yrelated treatmen-t includes prostheses and treatment for physical complications. 0%- After deductilbe Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. Network Providers 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) - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Benefits - See Covered Healthcare Dental Services for additional benefit limits and details. Network Providers 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) - for members under age 19 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% Not Covered Covered Benefits - After deductible 0% - After deductible See Covered Healthcare Services for additional benefit limits and 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 Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 2010% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2010% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 2010% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 2010% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 020% - 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. 020% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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 * 20% - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 020% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 20% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network providercare coordinated by Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Flex Plan (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay your primary care physician and permitted self-referrals. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 5020% - After deductible Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible 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 4020% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 4020% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 4020% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network providercare coordinated by your primary care physician and permitted self-referrals. 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 providercare coordinated by your primary care physician and permitted self-referrals.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Dental Services for additional benefit limits and details. Network Providers 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) - for members under age 19 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% $300 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Benefits - See Covered Healthcare Dental Services for additional benefit limits and details. Network Providers 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) - for members under age 19 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% Not Covered Covered Benefits - After deductible See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and Permitted Self-referrals Non-network Providers Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 2010% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2010% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 2010% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 2010% - After deductible The level of coverage is the same as network provider.. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 10% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $150 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible 40% - After deductible teet.h $40 40%- Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility* 0% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 20%- Afterdeductible 40%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits benefitlimits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible 20%- Afterdeductible 40% - After deductible Outpatient medical supplies* - Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible 20%- Afterdeductible 40% - After deductible Outpatient diabetic Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 20%- Afterdeductible 40% - After deductible Outpatient prosthesis* - Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible 20%- Afterdeductible 40% - After deductible Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 20%- Afterdeductible 40% - After deductible Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Asthma management $40 40% - Afterdeductible Emergency Room Services Hospitalemergencyroom $150 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam $40 40% - Afterdeductible Hearing diagnostic testing 0% 40% - Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for a member under 19; thbeenefit limis $700 per hearing aid for a member 19 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Intermittent skilled services whbeinlled by a home health care agency. 20%- Afterdeductible 40%- Afterdeductible Inpatien/tin your home. When provided by an approved hospice care program. 20%- Afterdeductible 40%- Afterdeductible Human leukocyte antigen testing 20%- Afterdeductible 40%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) -ivnitDro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in a P H liPfetimEe. H U ¶ V 20%- Afterdeductible 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefitlimits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Infusion Therapy- Administration Services Outpatient- hospital 20%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 20%- Afterdeductible 40%- Afterdeductible General hospitaol r specialty hospitaslervices*- unlimited days 20%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility service*s- limited to 45 days peprlan year. 20%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits 20%- Afterdeductible 40%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for details. 0% 40%- Afterdeductible Surgery services- includes mastectomy and reconstructi surgery. See Mastectomy Services in Section 3 for deta 0% 40%- Afterdeductible Mastectom-yrelated treatmen-t includes prostheses and treatment for physical complications. 0% Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - room- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $200 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0teet.h $50 20% - After deductible 40% - After deductible Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility outpatientfacility* 00%- Afterdeductible 20% - After deductible 40Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0%- Afterdeductible 20% - After deductible Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and detailsanddetails. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result re of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Asthma management 0% 20%- Afterdeductible Emergency Room Services Hospitalemergency room $200 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam $50 20%- Afterdeductible Hearing diagnostic testing 0% 20%- Afterdeductible Hearing aids- The benefit limit is $2,000 per hearing aid a member under 21, the benefit limit is $700 per hearing for amember 21 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Intermittent skilled services when billed by a home heal care agency. 0%- Afterdeductible 20%- Afterdeductible Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. LThreFe (3L)-ivniDtro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in Pa H lifetime. 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits anddetails. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospitaol r specialtyhospitalservices*- Unlimited Days 0%- Afterdeductible 20%- Afterdeductible Rehabilitationfacility service*s- Limited to 45 days peprlan year. 0%- Afterdeductible 20%- Afterdeductible Physicianhospitalvisits. 0%- Afterdeductible 20%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for deta 0% 20%- Afterdeductible Surgery services- includes mastectomy and reconstructiv surgery. See Mastectomy Services in Section 3 for detai 0% 20%- Afterdeductible Mastectom-yrelated treatmen-t includes protheses and treatment for physical complications. 0% Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible Not Covered Oral evaluations 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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 $100 The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $50 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible 40% - After deductible teet.h $15 20%- Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility* 0% - After deductible 4020%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0% - After deductible 20%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers NetworkProviders Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Outpatient medical supplies* - Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Outpatient diabetic Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 4020% - After deductible Outpatient prosthesis* - Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible 4020% - After deductible Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 4020% - After deductible Afterdeductible Enteral formula or food taken orally * ora*lly 20% - After deductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $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 providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Asthma management $15 20% - Afterdeductible Emergency Room Services Hospitalemergencyroom $50 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam $15 20% - Afterdeductible Hearing diagnostic testing 0% 20% - Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid for a member under 19; thbeenefit limis $700 per hearing aid for a member 19 and older. 20% The level of coverage is the same as network xxxxxx.xx Intermittent skilled services when billed by a hhoemaleth care agency. 0% 20%- Afterdeductible Inpatien/tin your home. When provided by an approved hospice care program. 0% 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) -ivnitDro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in a P H liPfetimEe. H U ¶ V 20% 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Infusion Therapy- Administration Services Outpatient- hospital 0% 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0% 20%- Afterdeductible General hospitaol r specialtyhospitalservices*- unlimited days 0% 20%- Afterdeductible Rehabilitationfacility service*s- limited to 45 days peprlan year. 0% 20%- Afterdeductible Physicianhospitalvisits 0% 20%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for details. 0% 20%- Afterdeductible Surgery services- includes mastectomy and reconstructi surgery. See Mastectomy Services in Section 3 for deta 0% 20%- Afterdeductible Mastectom-yrelated treatmen-t includes prostheses and treatment for physical complications. 0% Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible 40% - After deductible teet.h 0%- Afterdeductible 40%- Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility outpatientfacility * 0% - 0%- Afterdeductible 40%- Afterdeductible Dental Services (Pediatric)- for members under age 19: See Dental Services in Section 3 fboernefitlimitsand details. These services only apply to an enrolmledemberunder the age of 19. Oral evaluations 0%- Afterdeductible 0%- After deductible 40% - X-rays 0%- Afterdeductible 0%- After deductible Cleanings (prophylaxis) 0%- Afterdeductible 0%- After deductible Fluoride treatments 0%- Afterdeductible 0%- After deductible Sealants 0%- Afterdeductible 0%- After deductible Space Maintainers 0%- Afterdeductible 0%- After deductible Palliative treatment 0%- Afterdeductible 50%- After deductible Fillings 0%- Afterdeductible 50%- After deductible Simple extractions 0%- Afterdeductible 50%- After deductible Denture repairs and relines/rebasing 0%- Afterdeductible 50%- After deductible Crowns & onlays 0%- Afterdeductible 50%- After deductible Therapeutic Pulpotomies 0%- Afterdeductible 50%- After deductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Non-surgical periodontal services 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Surgical periodontal services 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Periodontal maintenance 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Fixed bridges and dentures 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Implants 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Oral surgery services 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible General anesthesia or IV sedation - dental sedatio-ndental office 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Biopsies 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Occlusal (night) guards 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - brace-s)whenmedically necessar.y 0%- Afterdeductible 50%- After deductible Inpatient/outpatientoutpatie/in nint your home 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - Must equipmen-t*Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must 0%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplies-*Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic 0%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - 0%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Enteral formula fomr ula or food taken orally * 20% - After deductible 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result re of cancer treatment. 20% - After deductible 0%- Afterdeductible The level of coverage is the same as network provider.xxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Asthma management 0%- Afterdeductible 40%- Afterdeductible Emergency Room Services Hospitalemergencyroom 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam 0%- Afterdeductible 40%- Afterdeductible Hearing diagnostic testing 0%- Afterdeductible 40%- Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid fo a memberunder 19; thebenefit limis $700 per hearing aid for amember19 and older. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Intermittent skilled services when billed by a home heal care agency. 0%- Afterdeductible 40%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 40%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0%- Afterdeductible 40%- Afterdeductible Infertility Services Inpatient/outpatiennt/ia S K o\ ffiVce. LThreFe (3L) D infertility treatment cycles will be coveredplpaenryearwith a total of eight (8) infertility treatment cycles covered in P H liPfetimEe. H U ¶ V 0%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 40%- Afterdeductible General hospitaol r specialtyhospitalservices*- unlimited days 0%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility services-*limited to 45 days peprlan year. 0%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 40%- Afterdeductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40Not Covered Dental Servces (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% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at 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.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - room- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound natural toousndnatural teeth. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility outpatientfacility* 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0%- Afterdeductible 40%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers 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) - 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result re of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Asthma management 0%- Afterdeductible 40%- Afterdeductible Emergency Room Services Hospitalemergency room 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam 0%- Afterdeductible 40%- Afterdeductible Hearing diagnostic testing 0%- Afterdeductible 40%- Afterdeductible Hearing aids T–he benefit limis $1,500 per hearing aid fo a member under 19; thbeenefit limis $700 per hearing aid for a member 19 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Intermittent skilled services whbeinlled by a home health care agency. 0%- Afterdeductible 40%- Afterdeductible Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 40%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0%- Afterdeductible 40%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. LThreFe (3L)-ivniDtro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in Pa H lifetime. 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospitaol r specialty hospitaslervices*- Unlimited Days 0%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility service*s- Limited to 45 days peprlan year. 0%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits. 0%- Afterdeductible 40%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for deta 0%- Afterdeductible 40%- Afterdeductible Surgery services- includes mastectomy and reconstructiv surgery. See Mastectomy Services in Section 3 for detai 0%- Afterdeductible 40%- Afterdeductible Mastectom-yrelated treatmen-t includes protheses and treatment for physical complications. 0%- Afterdeductible Coverage varies based on type of service.

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h $200 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible 40% - After deductible teet.h $50 20%- Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility a outpatientfacility* 0% - After deductible 40% - After deductible 0%- Afterdeductible 20%- Afterdeductible Dialysis Services Inpatient/outpatie/nint your home 0%- Afterdeductible 20%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. 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% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - equipme*n-t Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplie*s- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 20% - After deductible ora*lly 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible 20%- Afterdeductible The level of coverage is the same as network providerxxxxxx.xx Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Asthma management 0% 20%- Afterdeductible Emergency Room Services Hospitalemergencyroom $200 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam $50 20%- Afterdeductible Hearing diagnostic testing 0% 20%- Afterdeductible Hearing aids- The benefit limit is $2,000 per hearing aid for a member under 21, thbeenefit limit is $700 per hearing aid for a member 21 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Intermittent skilled services when billed by a home hea care agency. 0%- Afterdeductible 20%- Afterdeductible Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Service*s Inpatient/outpatiennt/ia S K o\ ffiVce. TLhreFe (3L) -ivnitDro fertilization cycles will be coveredpplaenr yearwith a total of eight (8) i-nvitro fertilization cycles covered in a P H liPfetimEe. H U ¶ V 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospitaol r specialty hospitaslervices*- unlimited days 0%- Afterdeductible 20%- Afterdeductible Rehabilitationfacility service*s- limited to 45 days peprlan year. 0%- Afterdeductible 20%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 20%- Afterdeductible Mastectomy Services Inpatient- see Mastectomy Services in Section 3 for details. 0% 20%- Afterdeductible Surgery services- includes mastectomy and reconstructi surgery. SeeMastectomy Services in Section 3 for detai 0% 20%- Afterdeductible Mastectom-yrelated treatmen-t includes prostheses and treatment for physical complications. 0% Coverage varies based on type of service. Office Visits- (Other than PreventiveCare Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injection-sapplies to injection only, including administration. 0% 20%- Afterdeductible Diabetic office visits Podiatristservices- first routine visit inpalan year $0 20%- Afterdeductible Vision care service-sfirst routine eye exam inpalan yearthat includes a retinal eye exam. $0 20%- Afterdeductible Hospitalbased clinic visits $50 20%- Afterdeductible PCP visits- including behavioral hea.ltVhisits includPeCP office visits anPdCP house calls and pediatric clinic visit $30 20%- Afterdeductible Retail clinics $30 20%- Afterdeductible Specialists Office visits and house calls renderedabsypecialist. Specialist includes but is not limited to allergists, dermatologists and xxxxxxxxxxXx.xx below for behavioral health specialist. $50 20%- Afterdeductible Office visits and house calls rendered by a behavioral health specialist. $30 20%- Afterdeductible Organ transplant services 0%- Afterdeductible 20%- Afterdeductible Physical/Occupational Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD 20%- Afterdeductible 40% Aftedr eductible Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. 0%- Afterdeductible 20%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), and notpurchased from a retail, specialty or mail order pharmacy: Injectable drug*s 0%- Afterdeductible 20%- Afterdeductible Infuseddrugs* 0%- Afterdeductible 20%- Afterdeductible Medications other than injected and infused d*rugs Are included in thaellowance for the medical service bein rendered. Are included in thaellowance for the medical service being rendered. Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section fo details. 0% 20%- Afterdeductible Private Duty Nursing Service*s Must be performed by a certified home health care age 0%- Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Inpatient 0%- Afterdeductible 20%- Afterdeductible Outpatient 0%- Afterdeductible 20%- Afterdeductible Skilled Care in a Nursing Facilit*y Skilled or su-bacute care 0%- Afterdeductible 20%- Afterdeductible Outpatient hospitainl/ a S K \ WV KL XX XX DD 20%- Afterdeductible 40%- Afterdeductible Inpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible Outpatientservices - includesphysicianservices and outpatient hospitaolr ambulatorysurgical centerfacility services. 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce. L F L D Q ¶ V 0% 20%- Afterdeductible Telemedicine Services When rendered by a designatepdrovider. $30 Not Covered When rendered by anetworkprovider. $30 Not Covered Outpatien,tin a S K o\ ffiVce, uLrgenFt caLre cDenterQor ¶ free-standing laboratory: Major diagnostic imaging and tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans PET scans, nuclear medicine and cardiac imaging. 0%- Afterdeductible 20%- Afterdeductible Sleep studies*. 0%- Afterdeductible 20%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted abov $75 20%- Afterdeductible Lab and pathology services. $25 20%- Afterdeductible Diagnostic colorectal servic-e(sIncluding, but not limited tof,ecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. S Prevention and Early Detection Services for preventive colorectal services.) 0%- Afterdeductible 20%- Afterdeductible Lyme disease diagnosis and treatment $25 20%- Afterdeductible Urgent care services $100 The level of coverage is the same as network xxxxxx.xx Vision Care Services Vision exam- one routine eye exam pemr emberper plan year. $0 20%- Afterdeductible Non-routine eyeexam $0 20%- Afterdeductible SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy.