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

Early Intervention Services (EIS). 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. Education - Asthma Asthma management $50 - After deductible 40% - After deductible Emergency Room Services Hospital emergency room $200 - After deductible The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $50 - After deductible 40% - After deductible Hearing diagnostic testing 0% - After deductible 40% - After deductible Hearing aids - The benefit limit is $1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 0% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible 40% - After deductible Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 40% - After deductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible 40% - After deductible Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 0% - After deductible 40% - After deductible Infusion Therapy - Administration Services Outpatient - facility 0% - After deductible 40% - After deductible In the physician’s office/in your home 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 Inpatient Services General hospital or specialty hospital services* - Unlimited Days 0% - After deductible 40% - After deductible Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible 40% - After deductible Physician hospital visits 0% - After deductible 40% - After deductible Mastectomy Services Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible 40% - After deductible Observation Services In a hospital or other health care facility 0% - After deductible 40% - After deductible Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible 40% - After deductible Hospital based clinic visits $50 - After deductible 40% - After deductible Pediatric clinic visit $30 - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $30 - After deductible 40% - After deductible Retail clinics $30 - After deductible 40% - After deductible Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $50 - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 - After deductible 40% - After deductible Organ Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

Early Intervention Services (EIS). 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. Education - Asthma Asthma management $50 0% - After deductible 40% - After deductible Emergency Room Services Hospital emergency room $200 - After deductible The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $50 0% - After deductible 40% - After deductible Hearing diagnostic testing 0% - After deductible 40% - After deductible Hearing aids - The benefit limit is $1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 020% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible 40% - After deductible Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 40% - After deductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible 40% - After deductible Infertility Services* 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. 020% - After deductible 40% - After deductible Infusion Therapy - Administration Services Outpatient - facility 0% - After deductible 40% - After deductible In the physician’s office/in your home 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 Inpatient Services General hospital or specialty hospital services* - Unlimited Days 0% - After deductible 40% - After deductible Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible 40% - After deductible Physician hospital visits 0% - After deductible 40% - After deductible Mastectomy Services Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible 40% - After deductible Observation Services In a hospital or other health care facility 0% - After deductible 40% - After deductible Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible 40% - After deductible Hospital based clinic visits $50 20 - After deductible 40% - After deductible Pediatric clinic visit visits $30 15 - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. $30 15 - After deductible 40% - After deductible Retail clinics $30 15 - After deductible 40% - After deductible Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $50 20 - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 15 - After deductible 40% - After deductible Organ Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

Early Intervention Services (EIS). 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. Education - Asthma Asthma management $50 - After deductible 400% - After deductible Not Covered Emergency Room Services Hospital emergency room $200 - After deductible 150 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $50 - After deductible 40% - After deductible 30 Not Covered Hearing diagnostic testing 0% - After deductible 40% - After deductible Not Covered Hearing aids - The benefit limit is $1,500 2,000 per hearing aid for a member under 19; 21, the benefit limit is $700 per hearing aid for a member 19 21 and older. 020% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible 40% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 40% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible 40% - After deductible Not Covered Infertility Services* Services Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization infertility treatment cycles will be covered per plan year with a total of eight (8) in-vitro fertilization infertility treatment cycles covered in a member’s lifetime. 020% - After deductible 40% - After deductible Not Covered Infusion Therapy - Administration Services Outpatient - facility hospital 0% - After deductible 40% - After deductible Not Covered In the physician’s office/in your home 0% - After deductible 40Not Covered Inpatient Services General hospital or specialty hospital services* - unlimited days 0% - After deductible Not Covered Rehabilitation facility services* - limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. $0 Not Covered Diabetic office visits: Podiatrist services - first routine visit in a plan year $0 Not Covered Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. $0 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 Inpatient Services General hospital or specialty hospital services* - Unlimited Days 0% - After deductible 40% - After deductible Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible 40% - After deductible Physician hospital visits 0% - After deductible 40% - After deductible Mastectomy Services Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible 40% - After deductible Observation Services In a hospital or other health care facility 0% - After deductible 40% - After deductible Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible 40% - After deductible Hospital based clinic visits $50 - After deductible 40% - After deductible Pediatric clinic visit $30 - After deductible 40% - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house callscalls and pediatric clinic visits. $30 - After deductible 40% - After deductible 20 Not Covered Retail clinics $30 20 Not Covered Specialists - After deductible 40% - After deductible Specialists Office office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. $50 - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 - After deductible 40% - After deductible Not Covered Organ Transplants Organ transplant services 0% - After deductible 40% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductibleNot Covered

Early Intervention Services (EIS). Coverage provided Coverageprovided for members from birth frombirth to 36 months. The provider must be mustbe certified as an EIS provider by the Rhode Island Department of Departmentof Human Services. 0% - After deductible The level of coverage is the same as network provider. Education - Asthma Asthma management $50 - After deductible 4040 20% plus $40 - After deductible Emergency Room Services Hospital emergency room $200 - After deductible 150 The level of coverage is the same as network provider. Experimental and Experimentaland Investigational Services Coverage varies based on Coveragevaries basedon type of serviceofservice. Hearing Services Hearing exam $50 - After deductible 4040 20% plus $40 - After deductible Hearing diagnostic testing 0% - After deductible 4020% - After deductible Hearing aids - The benefit limit is $1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 020% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible 4020% - After deductible Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 4020% - After deductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible 4020% - After deductible Infertility Services* Services 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. 020% - After deductible 4020% - After deductible Infusion Therapy - Administration Services Outpatient - facility 0% - After deductible 4020% - After deductible In the physician’s office/in your home 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand 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 Inpatient Services General hospital or specialty hospital services* - Unlimited Days unlimited days 0% - After deductible 4020% - After deductible Rehabilitation facility services* - Limited limited to 45 days per plan year. 0% - After deductible 4020% - After deductible Physician hospital visits 0% - After deductible 4020% - After deductible Mastectomy Services Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible 4020% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible 4020% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications, such as physical or occupational therapy. 0% - After deductible 4020% - After deductible Observation Services In a hospital or other health care facility facility. 0% - After deductible 4020% - After deductible Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visitsofficevisits.) Allergy injections - Applies applies to injection only, including administration. 0% - After deductible 4020% - After deductible Hospital based clinic visits $50 - After deductible 4040 20% plus $40 - After deductible Pediatric clinic visit $30 - After deductible 4025 20% plus $25 - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $30 - After deductible 4025 20% plus $25 - After deductible Retail clinics $30 - After deductible 4025 20% plus $25 - After deductible Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $50 - After deductible 4040 20% plus $40 - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 - After deductible 4025 20% plus $25 - After deductible Organ Transplants Organ transplant services transplantservices 0% - After deductible 4020% - After deductible Physical/Occupational Therapy Outpatient hospital/in hospital when therapy is rendered within the first 30- days following a physician’s/therapist’s officehospital stay; home care program or ambulatory surgical procedure. Limited to thirty (30) physical therapy visits and 30 occupational therapy visits per member per plan year. 0% - After deductible 4020% - After deductibledeductible Outpatient hospital (after the first 30 days) or in a doctor’s/therapist’s office. Limited to thirty (30) physical therapy visits and 30 occupational therapy visits per member per plan year. 20% - After deductible 20% - After deductible Pregnancyand Maternity Services Pre-natal, delivery, and postpartumservices. 0% - After deductible 20% - After deductible Prescription Drugsand Diabetic Equipment and Supplies Prescription drugs and diabetic equipmentand supplies dispensed at a pharmacy. See Summary of Pharmacy Covered Benefits - See Covered Healthcare Services for additionalbenefit limitsand 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 Benefits for prescription drugs purchased ata retail, specialty, or mail order pharmacy. Prescription drugs dispensed and administered by a licensed health care provider (other than a pharmacist), and not purchased froma retail, specialty or mail order pharmacy: Injectable drugs* Includes chemotherapy drugs used for other than cancer treatment. 20% - After deductible 20% - After deductible Infused drugs* Includes chemotherapy drugs used for other than cancer treatment. 20% - After deductible 20% - After deductible Limited to injectable and infused chemotherapy drugs used for cancer treatment.* 0% - After deductible 20% - After deductible Medications other than injected and infused drugs* Are included in the allowance for the medical service being rendered. Are included in the allowance for the medical service being rendered.