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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not Covered

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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $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 0% - After deductible $40 Not Covered Hearing diagnostic testing 0% - After deductible $30 Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and olderaid. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - 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 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 Not Covered

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 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $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 0% - After deductible $40 Not Covered Hearing diagnostic testing 0% - After deductible $30 Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not Covered

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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $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 0% - After deductible $40 Not Covered Hearing diagnostic testing 0% - After deductible $30 Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not Covered

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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not Covered

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% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% 20% - After deductible Emergency Room Services Hospital emergency room $200 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 $40 20% - After deductible Hearing diagnostic testing 0% 20% - After deductible Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21, the benefit limit is $700 per hearing aid for a member 21 and older. 20% - 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 20% - 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered 20% - After deductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20% - 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 Not Covered40% - 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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $200 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 0% - After deductible $50 Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not Covered

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% The level of coverage is the same as network provider. Education - Asthma Asthma management $25 - After deductible Not Covered Emergency Room Services Hospital emergency room $100 - 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0% $25 - After deductible Not Covered Hearing diagnostic testing 0% - 0%- After deductible Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and olderaid. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - 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 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 Not Covered

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% The level of coverage is the same as network provider. Education - Asthma Asthma management 10% - After deductible Not Covered Emergency Room Services Hospital emergency room 10% - 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 10% - After deductible Not Covered Hearing diagnostic testing 10% - After deductible Not Covered 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. 10% - 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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. 010% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 010% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 010% - 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. 010% - After deductible Not Covered

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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $200 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 0% - After deductible $45 Not Covered Hearing diagnostic testing 0% - After deductible $30 Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not CoveredCovered 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

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. 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 Education - Asthma Asthma management 0% - After deductible $25 Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $100 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 0% - After deductible $25 Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and olderaid. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - 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 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 Not Covered

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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $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 0% - After deductible $40 Not Covered Hearing diagnostic testing 0% - After deductible $30 Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not CoveredCovered 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

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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $200 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 0% - After deductible $50 Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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. 020% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 020% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not Covered

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. 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 Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered $200 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 0% - After deductible $40 Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - 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 Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered 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 Not Covered