Common use of Early Intervention Services (EIS) Clause in Contracts

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO 0% The level of coverage is the same as network provider. NO The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Education Asthma Management $0 NO 30% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $50 NO 30% YES Diagnostic Testing 10% YES 30% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 10% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 10% YES 30% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 10% YES 30% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 10% YES 30% YES Inpatient Physician Hospital Visits Inpatient 10% YES 30% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 10% YES 30% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $50 NO 30% YES Hospital based clinic visits for adults $50 NO 30% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) House Calls rendered by Specialist $50 NO 30% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Primary Care Physician (PCP) First non-preventive office visit in the calendar year rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per calendar year. $0 NO 30% YES Subsequent non- preventive office visits in the calendar year - PCP practices with PCMH model of care. $15 NO Subsequent non- preventive office visits in the calendar year - PCP does not practice with PCMH model of care. $35 NO Podiatrist Services Routine foot care is not covered. $50 NO 30% YES Retail Clinics See Section 3.23 – Office Visits for details. $50 NO 30% YES Specialist Visits Routine and non- routine visits. $50 NO 30% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Organ Transplants 10% YES 30% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 10% YES 30% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 10% YES 30% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 10% YES 30% YES Infused drugs 10% YES 30% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus:

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO 0% YES The level of coverage is the same as network provider. NO The level Education Asthma Management 0% YES Not Covered Not Covered Experimental/ Investigational Services Coverage varies based on type of coverage is the same as network providerservice. Hearing Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Education Asthma Management $0 NO 30% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $50 NO 30% YES Diagnostic Testing 10% YES 30% YES Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 100% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Coverage varies based on type of hemophilia service. 10% YES 30% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 100% YES 30% YES Not Covered Not Covered Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 100% YES 30% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 100% YES 30% YES Not Covered Not Covered Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 100% YES 30% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Office Visits Allergist & Dermatologist $50 NO 300% YES Not Covered Not Covered Hospital based clinic visits for adults $50 NO 300% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) House Calls rendered by Primary Care Physician Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Not Covered Not Covered House Calls rendered by Specialist $50 NO 300% YES Not Covered Not Covered Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Primary Care Physician (PCP) First non-preventive Sick Visit First, second, or third submitted claim for a sick office visit in the calendar year a benefit year. Benefit limit applies to all office visits rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per calendar yearexcept the annual preventive care office visits. $0 25 NO 30% YES Not Covered Not Covered Office Visits (other than Subsequent non- preventive submitted claims for sick office visits in the calendar year - PCP practices with PCMH model of carea benefit year. $15 NO Subsequent non- preventive office visits in the calendar year - PCP does not practice with PCMH model of care. $35 NO Podiatrist Services Routine foot care is not covered. $50 NO 300% YES Retail Clinics See Section 3.23 – Office Visits for details. $50 NO 30% YES Specialist Visits Routine and non- routine visits. $50 NO 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: office visits for Behavioral Health and annual preventive care) Primary Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Not Covered Not Covered Podiatrist Services Routine foot care is not covered. 0% YES Not Covered Not Covered Specialist Visits Routine and non- routine visits. 0% YES Not Covered Not Covered Organ Transplants 100% YES 30% YES Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 100% YES 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 100% YES 30% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 100% YES 30Not Covered Not Covered Infused drugs 0% YES Infused drugs 10% YES 30% YES Not Covered Not Covered Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Prevention and Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus:: Early Detection Services Prevention and Early Detection Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per benefit year. 0% NO Not Covered Not Covered Pediatric preventive clinic 0% NO Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0% NO Not Covered Not Covered Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO Not Covered Not Covered Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Services Prevention and Early Detection Services Allergy injections Applies to injection only including administration. 0% YES Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO Not Covered Not Covered Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO Not Covered Not Covered Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services for women Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care center, or free- standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. 0% YES Not Covered Not Covered For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Tests, Imaging*, and Labs (includes machine tests and x-rays) Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Vision Hardware for a member under the age of 19 One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Vision Hardware for a member under the age of 19 The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose vision can be corrected two lines of improvement. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Vision Hardware for a member under the age of 19 Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO 0% YES The level of coverage is the same as network provider. NO The level Education Asthma Management 0% YES Not Covered Not Covered Experimental/ Investigational Services Coverage varies based on type of coverage is the same as network providerservice. Hearing Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Education Asthma Management $0 NO 30% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $50 NO 30% YES Diagnostic Testing 10% YES 30% YES Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 100% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Coverage varies based on type of hemophilia service. 10% YES 30% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 100% YES 30% YES Not Covered Not Covered Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 100% YES 30% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 100% YES 30% YES Not Covered Not Covered Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 100% YES 30% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Office Visits Allergist & Dermatologist $50 NO 300% YES Not Covered Not Covered Hospital based clinic visits for adults $50 NO 300% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) House Calls rendered by Primary Care Physician Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Not Covered Not Covered House Calls rendered by Specialist $50 NO 300% YES Not Covered Not Covered Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Primary Care Physician (PCP) First non-preventive Sick Visit First, second, or third submitted claim for a sick office visit in the calendar year a benefit year. Benefit limit applies to all office visits rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per calendar yearexcept the annual preventive care office visits. $0 25 NO 30% YES Not Covered Not Covered Office Visits (other than Subsequent non- preventive submitted claims for sick office visits in the calendar year - PCP practices with PCMH model of carea benefit year. $15 NO Subsequent non- preventive office visits in the calendar year - PCP does not practice with PCMH model of care. $35 NO Podiatrist Services Routine foot care is not covered. $50 NO 300% YES Retail Clinics See Section 3.23 – Office Visits for details. $50 NO 30% YES Specialist Visits Routine and non- routine visits. $50 NO 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: office visits for Behavioral Health and annual preventive care) Primary Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Not Covered Not Covered Podiatrist Services Routine foot care is not covered. 0% YES Not Covered Not Covered Specialist Visits Routine and non- routine visits. 0% YES Not Covered Not Covered Organ Transplants 100% YES 30% YES Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 100% YES 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 100% YES 30% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 100% YES 30Not Covered Not Covered Infused drugs 0% YES Infused drugs 10% YES 30% YES Not Covered Not Covered Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus:.

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO YES 0% The level of coverage is the same as network provider. NO YES The level of coverage is the same as network provider. Education Asthma Management 0% YES 20% YES Experimental/ Investigational Services Coverage varies based on type of service. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Education Asthma Management $0 NO 30% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $50 NO 300% YES 20% YES Diagnostic Testing 100% YES 3020% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 100% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits 0% YES 20% YES for details. Coverage varies based on type of hemophilia service. 10% YES 30% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 3020% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type 0% YES 20% YES of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO 150 YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 100% YES 3020% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment in-vitro cycles will be covered per benefit year with a total of eight (8) infertility treatment in-vitro cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 3020% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 3020% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 3020% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 10% $200 Copay per admission YES 3020% YES Inpatient Physician Hospital Visits Inpatient 100% YES 3020% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 10$200 Copay per admission YES 20% YES 30% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $50 NO 30% YES Hospital based clinic visits for adults $50 NO 30% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) Allergist & Dermatologist $40 YES 20% YES Hospital based clinic visits for adults $40 YES 20% YES House Calls rendered by Primary Care Physician PCP practices with PCMH model of care. $15 YES 20% YES PCP does NOT practice with PCMH model of care. $35 House Calls rendered by Specialist $50 NO 3040 YES 20% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 30YES 20% YES PCP does NOT practice with PCMH model of care. $35 NO YES Primary Care Physician (PCP) First non-preventive office visit in the calendar year rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per calendar year. $0 NO 30% YES Subsequent non- preventive office visits in the calendar year - PCP practices with PCMH model of care. $15 NO Subsequent non- preventive office visits in the calendar year - YES 20% YES PCP does not NOT practice with PCMH model of care. $35 NO YES Podiatrist Services Routine foot care is not covered. $50 NO 3040 YES 20% YES Retail Clinics See Section 3.23 – Office Visits for details. $50 NO 30% 40 YES Specialist Visits Routine and non- routine visits. $50 NO 3020% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Office Visits (continued) Specialist Visits Routine and non- routine visits. $40 YES 20% YES Organ Transplants 100% YES 3020% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 10% $40 YES 3020% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 100% YES 3020% YES Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 100% YES 3020% YES Infused drugs 100% YES 3020% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus:: Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details.

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO 0% The level of coverage is the same as network provider. NO Education Asthma Management 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Education Asthma Management $0 NO 30% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $50 NO 30% YES Diagnostic Testing 10% YES 30% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 10% YES The level of coverage is Your copayment Does the same as network provider. deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 100% YES 30% YES Not Covered Not Covered Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 100% YES 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30Not Covered Not Covered Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES In Your copayment Does the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES deductible apply? Your copayment Does the deductible apply? Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 100% YES 30% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 100% YES 30% YES Not Covered Not Covered Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 100% YES 30% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $50 30 NO 30% YES Not Covered Not Covered Hospital based clinic visits for adults $50 30 NO 30% YES Not Covered Not Covered House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 30% YES Not Covered Not Covered PCP does NOT not practice with PCMH model of care. $35 25 NO House Calls rendered by Specialist $30 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) House Calls rendered by Specialist $50 NO 30% YES Pediatric Clinic visit PCP practices with PCMH model of care- subsequent office visits in calendar year. $15 NO Not Covered Not Covered PCP does not practice with PCMH model of care. $25 NO Primary Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Primary Care Physician (PCP) First non-preventive office visit in the calendar year rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per calendar year. $0 NO 30% YES Subsequent non- preventive office visits in the calendar year - PCP practices with PCMH model of care. $15 NO Subsequent non- preventive office visits in the calendar year - Not Covered Not Covered PCP does not practice with PCMH model of care. $35 25 NO Podiatrist Services Routine foot care is not covered. $50 30 NO 30% YES Not Covered Not Covered Retail Clinics See Section 3.23 – Office Visits for details. $50 30 NO 30% YES Not Covered Not Covered Specialist Visits Routine and non- routine visits. $50 30 NO 30Not Covered Not Covered Organ Transplants 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Organ Transplants 10% YES 30% YES Your copayment Does the deductible apply? Your copayment Does the deductible apply? Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 100% YES 30% YES Not Covered Not Covered Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 100% YES 30% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 100% YES 30Not Covered Not Covered Infused drugs 0% YES Infused drugs 10% YES 30% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus:: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details.

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO YES 0% The level of coverage is the same as network provider. NO YES The level of coverage is the same as network provider. Education Asthma Management 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Education Asthma Management $0 NO 30% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $50 NO 300% YES Not Covered Not Covered Diagnostic Testing 100% YES 30% YES Not Covered Not Covered Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 100% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Coverage varies based on type of hemophilia service. 10% YES 30% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. 0% YES Not Covered Not Covered Prescription drug Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Human Leukocyte Antigen Testing 0% YES Not Covered Not Covered Testing Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES Not Covered Not Covered Hospital based clinic visits for adults 0% YES Not Covered Not Covered House Calls rendered by personal care physician Xxxx Xxxxx First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES House Calls rendered by Specialist 0% YES Not Covered Not Covered Pediatric Clinic visit Sick Visit First, second, or third $25 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. Subsequent submitted claims for sick office visits in a benefit year. 0% YES Personal Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Hospice Care Inpatient/in your home When provided by an approved hospice Your copayment Does the deductible apply? Your copayment Does the deductible apply? Podiatrist Services Routine foot care programis not covered. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 100% YES 30Not Covered Not Covered Specialist Visits Routine and non-routine visits. 0% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 10Not Covered Not Covered Organ Transplants 0% YES 30Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. 0% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetimeNot Covered Not Covered Covered health care services include rehabilitative and habilitative services. Prescription drug coverage benefit level is based on type of service Pregnancy Services and site of serviceNursery Care Pre-natal, delivery, and postpartum services. See Summary of Pharmacy Benefits for details. 100% YES 30Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Infusion Therapy Outpatient provider (other than a pharmacist) Prescription drug coverage benefit level is based on type of service and site of service. Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. 10Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% YES 30NO Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 10% YES 30% YES Inpatient Physician Hospital Visits Inpatient 10% YES 30% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1 per benefit year. 100% YES 30% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $50 NO 30% YES Hospital based clinic visits for adults $50 NO 30% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Office Visits Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pediatric preventive clinic 0% NO Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0% NO Not Covered Not Covered Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO Not Covered Not Covered Smoking cessation counseling For nicotine replacement therapy (other than office visits for Behavioral Health NRT) and annual preventive care) (continued) House Calls rendered by Specialist $50 smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 30Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections Applies to injection only including administration. 0% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Primary Care Physician (PCP) First non-preventive office visit in the calendar year rendered by a PCP or Behavioral Health PCP. Benefit applies per memberNot Covered Not Covered Preventive screenings Coverage includes, per calendar year. $0 NO 30% YES Subsequent non- preventive office visits in the calendar year - PCP practices with PCMH model of care. $15 NO Subsequent non- preventive office visits in the calendar year - PCP does not practice with PCMH model of care. $35 NO Podiatrist Services Routine foot care but is not covered. $50 limited to, the following: mammograms, pap smear, PSA test, 0% NO 30% YES Retail Clinics See Section 3.23 – Office Visits for details. $50 NO 30% YES Specialist Visits Routine and non- routine visits. $50 NO 30% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Organ Transplants 10% YES 30% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 10% YES 30% YES Pregnancy Services and Nursery Care Pre-natalYour copayment Does the deductible apply? Your copayment Does the deductible apply? flexible sigmoidoscopy, deliverycolonoscopy, double contrast barium enema, and postpartum servicesfecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 10Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% YES 30% YES Prescription drugs, other than Specialty NO Not Covered Not Covered Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs). Are included in the allowance for the medical service being rendered. Injectable For prescription drugs 10% YES 30% YES Infused drugs 10% YES 30% YES Prescription Drugs Purchased purchased at a Retailpharmacy, Specialty, or Mail Order Pharmacy See see the Summary of Pharmacy Benefits for detailsBenefits. 0% NO Not Covered Not Covered Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus:: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? center, or free- standing laboratory • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? vision can be corrected two lines of improvement. Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. • Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site.